Provider Demographics
NPI:1255834016
Name:LIGUORI, MATTHEW ANTHONY (LCDC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:LIGUORI
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:1430 COLLIER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2911
Practice Address - Country:US
Practice Address - Phone:512-445-7787
Practice Address - Fax:512-440-4059
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14048101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101YA0400Medicaid