Healthcare Provider Details

I. General information

NPI: 1487390860
Provider Name (Legal Business Name): MATTHEW SMITH CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530A 5TH ST
BERKELEY CA
94710-1713
US

IV. Provider business mailing address

2933 MCCLURE ST APT 3
OAKLAND CA
94609-3561
US

V. Phone/Fax

Practice location:
  • Phone: 510-725-1179
  • Fax:
Mailing address:
  • Phone: 301-461-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number80573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: