Basic Information
| Provider Information | |||||||||
| NPI: | 1013275544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4908 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5230 W MOONLIGHT MINE RD. | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832018320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083513956 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2012 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCSW-36921 | ID | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | LMSW-32118 | ID | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LCSW-36921 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.