Provider Demographics
NPI:1770914491
Name:MATTHIS, INECIR
Entity type:Individual
Prefix:
First Name:INECIR
Middle Name:
Last Name:MATTHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 EMBARCADERO CV
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-5203
Mailing Address - Country:US
Mailing Address - Phone:510-535-1344
Mailing Address - Fax:510-535-1346
Practice Address - Street 1:3408 ANDOVER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2817
Practice Address - Country:US
Practice Address - Phone:510-547-1531
Practice Address - Fax:510-547-1543
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-M1307012358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health