Provider Demographics
NPI:1720708621
Name:LEIBFREID, MATTHEW JOHN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:LEIBFREID
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:CMR 402 BOX 1139
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-0012
Mailing Address - Country:US
Mailing Address - Phone:808-829-6686
Mailing Address - Fax:
Practice Address - Street 1:CMR 402, GENERAL DELIVERY (4 CORNERS)
Practice Address - Street 2:ATTN: AMIOP, WARD 3C
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:808-829-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3010-21R101YA0400X
HI302101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI302OtherHAWAII MENTAL HEALTH COUNSELOR LICENSE