Provider Demographics
NPI:1548561277
Name:VICARIO, MATTHEW JOSEPH (CMHC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:VICARIO
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 S WOODDUCK LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4935
Mailing Address - Country:US
Mailing Address - Phone:801-946-2323
Mailing Address - Fax:
Practice Address - Street 1:4055 S 700 E STE 204
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2504
Practice Address - Country:US
Practice Address - Phone:801-946-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5170621-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235447772Medicaid