Provider Demographics
NPI:1215579545
Name:MATIYA, KIRA MARIE
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:MARIE
Last Name:MATIYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 FULTON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-4366
Mailing Address - Country:US
Mailing Address - Phone:415-429-1682
Mailing Address - Fax:
Practice Address - Street 1:1801 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-2923
Practice Address - Country:US
Practice Address - Phone:415-681-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist