Provider Demographics
NPI:1700159852
Name:DUNHAM, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DUNHAM
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 1:49 E 200 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1047
Mailing Address - Country:US
Mailing Address - Phone:801-779-0095
Mailing Address - Fax:801-779-0255
Practice Address - Street 1:1120 STOCKS AVE STE 102
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3508
Practice Address - Country:US
Practice Address - Phone:801-896-5345
Practice Address - Fax:801-896-5334
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT86348136004106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor