Healthcare Provider Details

I. General information

NPI: 1255719464
Provider Name (Legal Business Name): MR. MATTHEW BOOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 KANSAS AVE
SAN LUIS OBISPO CA
93405-7604
US

IV. Provider business mailing address

1585 KANSAS AVE
SAN LUIS OBISPO CA
93405-7604
US

V. Phone/Fax

Practice location:
  • Phone: 619-300-2968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: