1275559965 NPI number — JAVIER MILTON MATOS LCSW

Table of content: JAVIER MILTON MATOS LCSW (NPI 1275559965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275559965 NPI number — JAVIER MILTON MATOS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATOS
Provider First Name:
JAVIER
Provider Middle Name:
MILTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATOS
Provider Other First Name:
JAVIER
Provider Other Middle Name:
MILTON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275559965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6014 60TH ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MASPETH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11378-3410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-386-8527
Provider Business Mailing Address Fax Number:
718-821-4499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6014 60TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MASPETH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11378-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-366-6252
Provider Business Practice Location Address Fax Number:
718-366-6253
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  069411 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02209263 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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