Provider Demographics
NPI:1366713075
Name:VINSON, MATTHEW (MSW, LCSW, CADC III)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:VINSON
Suffix:
Gender:M
Credentials:MSW, LCSW, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 NW SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1212
Mailing Address - Country:US
Mailing Address - Phone:541-891-9841
Mailing Address - Fax:
Practice Address - Street 1:1009 NW SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1212
Practice Address - Country:US
Practice Address - Phone:541-891-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-05-19101YA0400X
171M00000X
OR77851041C0700X
ORL77851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657181Medicaid
OR500714484Medicaid