Healthcare Provider Details

I. General information

NPI: 1255185484
Provider Name (Legal Business Name): MATTHEW STARR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 10/03/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SIMPSON AVE STE 101
ABERDEEN WA
98520-4333
US

IV. Provider business mailing address

COLUMBIA WELLNESS PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-612-0012
  • Fax: 360-532-0670
Mailing address:
  • Phone: 360-353-9369
  • Fax: 360-577-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61543679
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG61543679
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: