Provider Demographics
NPI:1285112433
Name:ROBERTS, MATTHEW IRA (CP 61222010)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:IRA
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:CP 61222010
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 S LANE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2829
Mailing Address - Country:US
Mailing Address - Phone:253-355-9888
Mailing Address - Fax:
Practice Address - Street 1:1601 W MEEKER ST STE 201
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4323
Practice Address - Country:US
Practice Address - Phone:206-550-5894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61222010101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)