Provider Demographics
NPI:1194204289
Name:BECKER, MATTNI
Entity type:Individual
Prefix:
First Name:MATTNI
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 E RICHARDS ST STE 9&10
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3089
Mailing Address - Country:US
Mailing Address - Phone:307-222-3042
Mailing Address - Fax:
Practice Address - Street 1:1954 E RICHARDS ST STE 9&10
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-3089
Practice Address - Country:US
Practice Address - Phone:307-222-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1306101YM0800X
172V00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker