=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194906404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAMES CAMARENA M.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2842 ROCKRIDGE DR
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-8623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-421-0859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2842 ROCKRIDGE DR
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-8623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-421-0859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 35230
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------