Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | LCSW-582 | WY |
NPI | 1003100181 |
---|---|
Provider Name | Matthew Ty Barrus |
First Address | Powell, WY 82435-8473 |
Second Address | Powell, WY 82435-1632 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2011 |
Last Update Date | 06/06/2011 |