Provider Demographics
NPI:1982472197
Name:HEEREMA, MATTHEW R
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:HEEREMA
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 1:4807 WILLOW TRL
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-2573
Mailing Address - Country:US
Mailing Address - Phone:508-277-2494
Mailing Address - Fax:
Practice Address - Street 1:4807 WILLOW TRL
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-2573
Practice Address - Country:US
Practice Address - Phone:508-277-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10000875101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health