Provider Demographics
NPI:1457931628
Name:WEISE, MATTHEW DANIEL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DANIEL
Last Name:WEISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 DAISY PATCH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6363
Mailing Address - Country:US
Mailing Address - Phone:702-449-5159
Mailing Address - Fax:
Practice Address - Street 1:2821 W HORIZON RIDGE PKWY STE 130
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4429
Practice Address - Country:US
Practice Address - Phone:702-840-1182
Practice Address - Fax:702-436-2593
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician