Provider Demographics
NPI:1407303290
Name:SPELLMAN, MATTHEW (RADT-I)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SPELLMAN
Suffix:
Gender:M
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 FOUNTAIN AVE
Mailing Address - Street 2:APT 302
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-2555
Mailing Address - Country:US
Mailing Address - Phone:949-438-8771
Mailing Address - Fax:
Practice Address - Street 1:8440 FOUNTAIN AVE
Practice Address - Street 2:APT 302
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-2555
Practice Address - Country:US
Practice Address - Phone:949-438-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1229940516101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)