Provider Demographics
NPI:1912017187
Name:MATISE, MILES (LPC)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:MATISE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-3835
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:970-353-3906
Practice Address - Street 1:1306 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-3835
Practice Address - Country:US
Practice Address - Phone:970-347-2120
Practice Address - Fax:970-353-3906
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4120OtherLPC