Healthcare Provider Details

I. General information

NPI: 1689264384
Provider Name (Legal Business Name): MATTHEW DAVID HUETHER PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 3RD AVE SE STE 501
CEDAR RAPIDS IA
52401-1542
US

IV. Provider business mailing address

4626 ASPEN LN NE
CEDAR RAPIDS IA
52402-2204
US

V. Phone/Fax

Practice location:
  • Phone: 563-920-7860
  • Fax:
Mailing address:
  • Phone: 563-920-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG162113
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: