Healthcare Provider Details

I. General information

NPI: 1861311565
Provider Name (Legal Business Name): MATTHEW NIETO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22365 LANCASTER CT
NOVI MI
48374-3974
US

IV. Provider business mailing address

8599 PINE COVE DR
COMMERCE TOWNSHIP MI
48382-4457
US

V. Phone/Fax

Practice location:
  • Phone: 248-266-5775
  • Fax:
Mailing address:
  • Phone: 248-444-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: