Provider Demographics
NPI:1124398599
Name:MATCHAM, ATHEENA MARIE (MA, MFTI 65169)
Entity Type:Individual
Prefix:
First Name:ATHEENA
Middle Name:MARIE
Last Name:MATCHAM
Suffix:
Gender:F
Credentials:MA, MFTI 65169
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-5236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1426 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-5236
Practice Address - Country:US
Practice Address - Phone:415-202-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2017-05-03
Deactivation Date:2015-03-03
Deactivation Code:
Reactivation Date:2017-05-03
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 65169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist