Provider Demographics
NPI:1124593017
Name:MATTHEWS, ELISA MARIE (BA)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 ORCHARD ST W
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3824
Mailing Address - Country:US
Mailing Address - Phone:253-414-7461
Mailing Address - Fax:253-627-8387
Practice Address - Street 1:5315 S ORCHARD ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3686
Practice Address - Country:US
Practice Address - Phone:253-414-7461
Practice Address - Fax:253-627-8387
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60846558Medicaid