Provider Demographics
NPI:1972199701
Name:BLOSS, MATTHEW RYAN (LSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:BLOSS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SPRING MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:ZION GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17985-9313
Mailing Address - Country:US
Mailing Address - Phone:570-590-8765
Mailing Address - Fax:
Practice Address - Street 1:1300 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:PA
Practice Address - Zip Code:18433-1973
Practice Address - Country:US
Practice Address - Phone:570-281-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137522104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker