Provider Demographics
NPI:1154173649
Name:BALTAZAR, MATTHEW CALVIN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CALVIN
Last Name:BALTAZAR
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 1:9359 FOX RUN
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-8706
Mailing Address - Country:US
Mailing Address - Phone:269-369-8239
Mailing Address - Fax:
Practice Address - Street 1:1485 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5711
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:269-927-1326
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor