Provider Demographics
NPI:1174381917
Name:STANLEY, MATTHEW L (LMHC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:STANLEY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 SAMS HILL RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-9685
Mailing Address - Country:US
Mailing Address - Phone:812-360-4847
Mailing Address - Fax:
Practice Address - Street 1:205 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-6128
Practice Address - Country:US
Practice Address - Phone:812-360-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99123673A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health