=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912459330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW MILBURN PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2016
-----------------------------------------------------
Last Update Date | 02/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10333 EL CAMINO REAL
-----------------------------------------------------
City | ATASCADERO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93422-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-468-2976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10333 EL CAMINO REAL
-----------------------------------------------------
City | ATASCADERO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93422-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-468-2976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 28765
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 023382
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------