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General NPI Number Information
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NPI Number | 1164019303
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Entity Type | Individual
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Provider Name | MATTHEW BLAISE MCDANIEL LMSW
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Gender | Male
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Dates
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Enumeration Date | 12/22/2020
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Last Update Date | 12/22/2020
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Provider Practice Location Address
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Address Line | 9196 W BARNES DR
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City | BOISE
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State | ID
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Zip | 83709-1552
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Country | US
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Telephone | 208-433-0400
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Fax | 208-378-5824
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Provider Business Mailing Address
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Address Line | 9196 W BARNES DR
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City | BOISE
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State | ID
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Zip | 83709-1552
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Country | US
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Telephone | 208-433-4000
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Fax | 208-378-5824
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LMSW-38732
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License Number State | ID
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