Healthcare Provider Details

I. General information

NPI: 1689446304
Provider Name (Legal Business Name): MATTHEW VANDE VREDE CB61419139
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 112TH AVE NE STE 206
BELLEVUE WA
98004-3759
US

IV. Provider business mailing address

1380 112TH AVE NE STE 206
BELLEVUE WA
98004-3759
US

V. Phone/Fax

Practice location:
  • Phone: 425-754-5135
  • Fax:
Mailing address:
  • Phone: 425-754-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61419139
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: