Provider Demographics
NPI:1447559760
Name:MATZ, KYLE G (LMFT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:G
Last Name:MATZ
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0101
Mailing Address - Country:US
Mailing Address - Phone:541-430-2096
Mailing Address - Fax:541-637-0849
Practice Address - Street 1:2713 W HARVARD AVE STE 90
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2600
Practice Address - Country:US
Practice Address - Phone:541-430-2096
Practice Address - Fax:541-637-0849
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500646717Medicaid