Provider Demographics
NPI:1043099971
Name:MCCLUSKEY, MATTHEW COLMAN (RADT-1)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:COLMAN
Last Name:MCCLUSKEY
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 BELL RD # 214
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2540
Mailing Address - Country:US
Mailing Address - Phone:916-208-2259
Mailing Address - Fax:
Practice Address - Street 1:2844 COLOMA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4406
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1514310723101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)