Provider Demographics
NPI:1386092856
Name:SMITH, MATTHEW (QMHA- PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:QMHA- PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0001
Mailing Address - Country:US
Mailing Address - Phone:541-942-3939
Mailing Address - Fax:
Practice Address - Street 1:1345 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1416
Practice Address - Country:US
Practice Address - Phone:541-942-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker