Provider Demographics
NPI:1689446304
Name:VANDE VREDE, MATTHEW (CB61419139)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VANDE VREDE
Suffix:
Gender:M
Credentials:CB61419139
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 112TH AVE NE STE 206
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3759
Mailing Address - Country:US
Mailing Address - Phone:425-754-5135
Mailing Address - Fax:
Practice Address - Street 1:1380 112TH AVE NE STE 206
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3759
Practice Address - Country:US
Practice Address - Phone:425-754-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61419139106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician