Healthcare Provider Details

I. General information

NPI: 1558397364
Provider Name (Legal Business Name): HENRY MADDOX MATTHEWS JR. LPC, CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/23/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 STAPLES MILL RD
RICHMOND VA
23228-5427
US

IV. Provider business mailing address

5821 STAPLES MILL RD
RICHMOND VA
23228-5427
US

V. Phone/Fax

Practice location:
  • Phone: 804-264-0966
  • Fax: 804-264-1029
Mailing address:
  • Phone: 804-264-0966
  • Fax: 804-264-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710101983
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0701003879
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: