Provider Demographics
NPI:1467925875
Name:WADZITA, MATTHEW E
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:E
Last Name:WADZITA
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 1:12503 SE MILL PLAIN BLVD STE 119A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4007
Mailing Address - Country:US
Mailing Address - Phone:360-314-6507
Mailing Address - Fax:360-852-8041
Practice Address - Street 1:12503 SE MILL PLAIN BLVD STE 119A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4007
Practice Address - Country:US
Practice Address - Phone:360-314-6507
Practice Address - Fax:360-852-8041
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61160894101YM0800X
ORC6973101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health