Provider Demographics
NPI:1730327800
Name:MATIAS, MICHAEL MARTIN (CASAC 8616)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MARTIN
Last Name:MATIAS
Suffix:
Gender:M
Credentials:CASAC 8616
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BROWN PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4109
Mailing Address - Country:US
Mailing Address - Phone:917-567-5007
Mailing Address - Fax:718-503-7751
Practice Address - Street 1:211 BROWN PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-4109
Practice Address - Country:US
Practice Address - Phone:917-567-5007
Practice Address - Fax:718-503-7751
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)