Provider Demographics
NPI:1992180871
Name:KNIFONG, MATTHEW KEVIN (RADT-1)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KEVIN
Last Name:KNIFONG
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 ETHAN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2214
Mailing Address - Country:US
Mailing Address - Phone:916-223-7178
Mailing Address - Fax:
Practice Address - Street 1:1446 ETHAN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2214
Practice Address - Country:US
Practice Address - Phone:916-223-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1205960715101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)