Healthcare Provider Details

I. General information

NPI: 1114654506
Provider Name (Legal Business Name): MATTHEW WADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

IV. Provider business mailing address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

V. Phone/Fax

Practice location:
  • Phone: 626-633-2593
  • Fax:
Mailing address:
  • Phone: 626-633-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15530-RAC
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: