Provider Demographics
NPI:1861986317
Name:AUSTIN, MATTHEW WEBER
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WEBER
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-9696
Mailing Address - Country:US
Mailing Address - Phone:616-915-3169
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-663-9483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016699101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401016699Medicaid