Provider Demographics
NPI:1518606953
Name:KIJAK, MATTHEW (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KIJAK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N AVENUE 56
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1118
Mailing Address - Country:US
Mailing Address - Phone:909-451-9901
Mailing Address - Fax:
Practice Address - Street 1:1701 N AVENUE 56
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1118
Practice Address - Country:US
Practice Address - Phone:909-451-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW93903101YM0800X
CA171M00000X
CA1111791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator