Provider Demographics
NPI:1093869554
Name:ELIJAH, MATHEWS M (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MATHEWS
Middle Name:M
Last Name:ELIJAH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14402
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406
Mailing Address - Country:US
Mailing Address - Phone:805-748-9090
Mailing Address - Fax:
Practice Address - Street 1:1115 TURO ST SUITE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93406
Practice Address - Country:US
Practice Address - Phone:805-748-9090
Practice Address - Fax:805-781-6411
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39223106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist