Healthcare Provider Details

I. General information

NPI: 1083127583
Provider Name (Legal Business Name): MATTHEW ALEXANDER KUZMICH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4975 SE DIVISION ST APT 248
PORTLAND OR
97206-1574
US

IV. Provider business mailing address

4975 SE DIVISION ST APT 248
PORTLAND OR
97206-1574
US

V. Phone/Fax

Practice location:
  • Phone: 408-398-9622
  • Fax:
Mailing address:
  • Phone: 408-398-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCW95731
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL15075
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: