Healthcare Provider Details

I. General information

NPI: 1447559760
Provider Name (Legal Business Name): KYLE G MATZ LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2713 W HARVARD AVE STE 90
ROSEBURG OR
97471-2600
US

IV. Provider business mailing address

PO BOX 398
ROSEBURG OR
97470-0101
US

V. Phone/Fax

Practice location:
  • Phone: 541-430-2096
  • Fax: 541-637-0849
Mailing address:
  • Phone: 541-430-2096
  • Fax: 541-637-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0726
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: