Provider Demographics
NPI:1639741820
Name:MASOLINI, MATTHEW
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MASOLINI
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 1:4000 BIRCH ST STE 112
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2255
Mailing Address - Country:US
Mailing Address - Phone:949-629-3722
Mailing Address - Fax:
Practice Address - Street 1:4000 BIRCH ST STE 112
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2255
Practice Address - Country:US
Practice Address - Phone:949-629-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125554101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor