Healthcare Provider Details

I. General information

NPI: 1073759049
Provider Name (Legal Business Name): KIMBERLY REED MATIAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W HAYS ST
BOISE ID
83702-5511
US

IV. Provider business mailing address

610 W HAYS ST
BOISE ID
83702-5511
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7070
  • Fax: 208-381-7092
Mailing address:
  • Phone: 208-381-7070
  • Fax: 208-381-7092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-33136
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMSW-29187
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: