Healthcare Provider Details

I. General information

NPI: 1649658311
Provider Name (Legal Business Name): MATTHEW CIPOLLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28465 OLD TOWN FRONT ST STE 212
TEMECULA CA
92590-1821
US

IV. Provider business mailing address

1282 OAK DR
VISTA CA
92084-4663
US

V. Phone/Fax

Practice location:
  • Phone: 951-444-2105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: