Basic Information
| Provider Information | |||||||||
| NPI: | 1457026999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAMS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 668 | ||||||||
| Address2: | |||||||||
| City: | CAMP SHERMAN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977300668 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWTHORNE AVE SE STE A130 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | R6981 | OR | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | R6981 | OR | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | R6981 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | R6981 | 01 | OR | OREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS | OTHER |