Provider Demographics
NPI:1104291186
Name:WILLMS, MATTHEW R (MA, DCR)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:WILLMS
Suffix:
Gender:M
Credentials:MA, DCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6129
Mailing Address - Country:US
Mailing Address - Phone:360-457-0431
Mailing Address - Fax:360-457-0493
Practice Address - Street 1:327 E 11TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7931
Practice Address - Country:US
Practice Address - Phone:206-940-9357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health