Provider Demographics
NPI:1952701732
Name:FONTES, MATHEW GREGORY (MA)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:GREGORY
Last Name:FONTES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-4026
Mailing Address - Country:US
Mailing Address - Phone:530-458-5501
Mailing Address - Fax:530-458-8660
Practice Address - Street 1:3710 HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-4026
Practice Address - Country:US
Practice Address - Phone:530-458-5501
Practice Address - Fax:530-458-8660
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12762101YM0800X
CALPCC8490101YM0800X
FLMT3972106H00000X
CALMFT138254106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health