Provider Demographics
NPI:1407137078
Name:ELIAS, MATTHEW JOHN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:ELIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 SANTA ROSA AVE # 169
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7683
Mailing Address - Country:US
Mailing Address - Phone:707-565-4922
Mailing Address - Fax:
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-565-4922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73667106H00000X
CA102242106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist