Provider Demographics
NPI:1245441476
Name:DAVID, MATTHEW (LPCC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:DAVID
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:CERRILLOS
Mailing Address - State:NM
Mailing Address - Zip Code:87010-0207
Mailing Address - Country:US
Mailing Address - Phone:505-984-5525
Mailing Address - Fax:
Practice Address - Street 1:1807 2ND ST
Practice Address - Street 2:SUITE 44
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3499
Practice Address - Country:US
Practice Address - Phone:505-984-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0091351101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health