Provider Demographics
NPI:1912619495
Name:PRATT, MATTHEW A (LPC-IT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:PRATT
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 S LAKE DR APT 7
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5925
Mailing Address - Country:US
Mailing Address - Phone:937-631-3806
Mailing Address - Fax:
Practice Address - Street 1:2727 N GRANDVIEW BLVD STE 203
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1671
Practice Address - Country:US
Practice Address - Phone:262-547-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7135-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional