Provider Demographics
NPI:1285348441
Name:MATTHEWS, MICHAEL MCLANE (CCMA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MCLANE
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:512-661-8103
Mailing Address - Fax:
Practice Address - Street 1:1950 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6852
Practice Address - Country:US
Practice Address - Phone:714-547-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
T7A7N8C3363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician