Provider Demographics
NPI:1255570776
Name:GOSLINE, MATTHEW THOMAS (LCSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:GOSLINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9210
Mailing Address - Country:US
Mailing Address - Phone:208-336-4504
Mailing Address - Fax:208-336-0720
Practice Address - Street 1:411 N ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9210
Practice Address - Country:US
Practice Address - Phone:208-336-4504
Practice Address - Fax:208-336-0720
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-314281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical