Provider Demographics
NPI:1164019303
Name:MCDANIEL, MATTHEW BLAISE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BLAISE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9196 W BARNES DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1552
Mailing Address - Country:US
Mailing Address - Phone:208-433-4000
Mailing Address - Fax:208-378-5824
Practice Address - Street 1:9196 W BARNES DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1552
Practice Address - Country:US
Practice Address - Phone:208-433-0400
Practice Address - Fax:208-378-5824
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38732101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)