Provider Demographics
NPI:1639225071
Name:THEELER, MATTHEW WAYNE SR (CADC1)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:THEELER
Suffix:SR
Gender:M
Credentials:CADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 GREENCREST ST NE
Mailing Address - Street 2:NE
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4982
Mailing Address - Country:US
Mailing Address - Phone:503-371-0059
Mailing Address - Fax:
Practice Address - Street 1:399 YOUNG ST
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-4817
Practice Address - Country:US
Practice Address - Phone:503-981-5265
Practice Address - Fax:503-981-8736
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04-07-46171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator