Healthcare Provider Details

I. General information

NPI: 1457842999
Provider Name (Legal Business Name): MATTHEW NERE MCCUSKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1682 NOVATO BLVD
NOVATO CA
94947
US

IV. Provider business mailing address

555 NORTHGATE DR
SAN RAFAEL CA
94903-3680
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-3240
  • Fax:
Mailing address:
  • Phone: 415-526-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: