Healthcare Provider Details

I. General information

NPI: 1538579628
Provider Name (Legal Business Name): MATTHEW ERIK MCGIFFEN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRISON RD
REPRESA CA
95671-3258
US

IV. Provider business mailing address

11951 HESPERIA RD
HESPERIA CA
92345-1855
US

V. Phone/Fax

Practice location:
  • Phone: 916-985-8610
  • Fax:
Mailing address:
  • Phone: 760-956-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number92148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number67774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: