Basic Information
| Provider Information | |||||||||
| NPI: | 1316277015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOCKSTILL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DANA | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC, NCC, LCAS-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2920 HIGHWOODS BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276040010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774984490 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 SUNNYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192356510 | ||||||||
| FaxNumber: | 9192310314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2010 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 22224 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 8491 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 8491 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1316277015 | 05 | NC | MEDICAID |