Provider Demographics
NPI:1750946745
Name:BUKOWSKI, MATTHEW VERNON (LPC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:VERNON
Last Name:BUKOWSKI
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 LEAKE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5476
Mailing Address - Country:US
Mailing Address - Phone:434-270-0571
Mailing Address - Fax:240-595-6198
Practice Address - Street 1:1001 E MARKET ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5381
Practice Address - Country:US
Practice Address - Phone:434-270-0571
Practice Address - Fax:240-595-6198
Is Sole Proprietor?:No
Enumeration Date:2019-05-05
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007508101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor