Healthcare Provider Details

I. General information

NPI: 1447754742
Provider Name (Legal Business Name): MATT MACARTHUR VAN BLAIR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 AGNES AVE
SANTA MARIA CA
93458-2838
US

IV. Provider business mailing address

116 AGNES AVE
SANTA MARIA CA
93458-2838
US

V. Phone/Fax

Practice location:
  • Phone: 805-457-3724
  • Fax:
Mailing address:
  • Phone: 805-457-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number37368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: