=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023907359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW FETH CSWA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2025
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 ORCHARD HEIGHTS RD NW
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97304-3186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-558-9382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 C ST APT 209
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97351-2063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-558-9382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | A16716
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------