Provider Demographics
NPI:1033732060
Name:MATISES, AMANDA EMILY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:EMILY
Last Name:MATISES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 EASTBOURNE CRES
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4838
Mailing Address - Country:US
Mailing Address - Phone:631-569-9337
Mailing Address - Fax:
Practice Address - Street 1:669 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2314
Practice Address - Country:US
Practice Address - Phone:516-799-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024614OtherNYS OT LICENCE