Provider Demographics
NPI:1467644849
Name:MATSUURA, SCOTT SHIGEJI (LCSW 85567)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:SHIGEJI
Last Name:MATSUURA
Suffix:
Gender:M
Credentials:LCSW 85567
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 GRAVENSTEIN HWY N
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2607
Mailing Address - Country:US
Mailing Address - Phone:707-823-7300
Mailing Address - Fax:707-445-1802
Practice Address - Street 1:1800 GRAVENSTEIN HWY N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2607
Practice Address - Country:US
Practice Address - Phone:707-823-7300
Practice Address - Fax:707-823-3410
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA855671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor