Provider Demographics
NPI:1992471403
Name:WILKEN, MATHEW A
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:A
Last Name:WILKEN
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 1:15436 LA MIRADA BLVD # HH210
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5061
Mailing Address - Country:US
Mailing Address - Phone:562-481-9484
Mailing Address - Fax:
Practice Address - Street 1:8135 PAINTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-3168
Practice Address - Country:US
Practice Address - Phone:562-698-6600
Practice Address - Fax:562-698-6613
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6094224Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant