Provider Demographics
NPI:1194912675
Name:ALVARADO, MATTHEW SHANCE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANCE
Last Name:ALVARADO
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 1:1111 W FIR ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-5826
Mailing Address - Country:US
Mailing Address - Phone:505-356-5221
Mailing Address - Fax:
Practice Address - Street 1:1111 W FIR ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5826
Practice Address - Country:US
Practice Address - Phone:505-356-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT - 0102691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health