Provider Demographics
NPI:1427147651
Name:NOVAK, MATTHEW P (PH D)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20364 HIGHWAY 28 W
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-8429
Mailing Address - Country:US
Mailing Address - Phone:573-528-7884
Mailing Address - Fax:
Practice Address - Street 1:1450 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3648
Practice Address - Country:US
Practice Address - Phone:573-364-7551
Practice Address - Fax:573-364-4898
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004005475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical