Provider Demographics
NPI:1669160057
Name:VITEMB, MATTHEW J (LCSW, RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:VITEMB
Suffix:
Gender:M
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7607 EASTCREST DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-1409
Mailing Address - Country:US
Mailing Address - Phone:817-992-5608
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD STE L1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8652
Practice Address - Country:US
Practice Address - Phone:817-992-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1123431163W00000X
TX597351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse