=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861311565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW NIETO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2026
-----------------------------------------------------
Last Update Date | 07/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22365 LANCASTER CT
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48374-3974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-266-5775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8599 PINE COVE DR
-----------------------------------------------------
City | COMMERCE TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48382-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-444-7695
-----------------------------------------------------
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 | 6451025190
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------