Basic Information
| Provider Information | |||||||||
| NPI: | 1669946471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAMINSKI | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PEER SUPPORT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3637 GREEN RD STE 3G | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162208774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3637 GREEN RD STE 3G | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162208774 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 0064 | OH | Y |
No ID Information.