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General NPI Number Information
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NPI Number | 1538636774
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Entity Type | Individual
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Provider Name | MATTHEW JOHN RAITH
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Gender | Male
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Dates
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Enumeration Date | 10/25/2018
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Last Update Date | 10/25/2018
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Provider Practice Location Address
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Address Line | 1155 THIRD AVE
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City | CHULA VISTA
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State | CA
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Zip | 91911-3136
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Country | US
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Telephone | 619-498-8260
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Fax |
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Provider Business Mailing Address
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Address Line | 25266 BARQUE WAY
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City | DANA POINT
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State | CA
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Zip | 92629-1403
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Country | US
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Telephone | 949-310-4910
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Fax |
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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 | R1242790217
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License Number State | RI
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