Healthcare Provider Details

I. General information

NPI: 1144921990
Provider Name (Legal Business Name): MATTHEW ADAM HENSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SW EMKAY DR STE 104
BEND OR
97702-1043
US

IV. Provider business mailing address

1244 NE 4TH ST APT 9
BEND OR
97701-4301
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-8459
  • Fax:
Mailing address:
  • Phone: 541-419-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: