Provider Demographics
NPI:1710713441
Name:GOSSARD, MATHEW J (LMSW)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:J
Last Name:GOSSARD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 N CAMDEN PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5772
Mailing Address - Country:US
Mailing Address - Phone:208-861-5704
Mailing Address - Fax:
Practice Address - Street 1:2000 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:801-746-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6261171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker