Provider Demographics
NPI:1457646895
Name:KAM, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:KAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4650 HAWTHORNE RD STE 3B
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2376
Mailing Address - Country:US
Mailing Address - Phone:208-252-5621
Mailing Address - Fax:208-648-4167
Practice Address - Street 1:4650 HAWTHORNE RD STE 3B
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-252-5621
Practice Address - Fax:208-648-4167
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IDLPC5260106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health