Provider Demographics
NPI:1629658380
Name:KOTECKI, MATTHEW JASON (BSHS)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JASON
Last Name:KOTECKI
Suffix:
Gender:M
Credentials:BSHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13206 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9406
Mailing Address - Country:US
Mailing Address - Phone:616-422-4270
Mailing Address - Fax:
Practice Address - Street 1:1022 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022
Practice Address - Country:US
Practice Address - Phone:269-962-0051
Practice Address - Fax:269-962-0123
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)