Provider Demographics
NPI:1710085634
Name:MATTHEWS, MARK ALAN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:1515 N STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1526
Practice Address - Country:US
Practice Address - Phone:248-542-6070
Practice Address - Fax:248-542-3210
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006744101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor