Healthcare Provider Details

I. General information

NPI: 1407137078
Provider Name (Legal Business Name): MATTHEW JOHN ELIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

2665 SANTA ROSA AVE # 169
SANTA ROSA CA
95407-7683
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4922
  • Fax:
Mailing address:
  • Phone: 707-565-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number73667
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number102242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: