Provider Demographics
NPI:1053674580
Name:MATERASSO, JODIANNE (MSED)
Entity Type:Individual
Prefix:
First Name:JODIANNE
Middle Name:
Last Name:MATERASSO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1140
Mailing Address - Country:US
Mailing Address - Phone:914-755-6373
Mailing Address - Fax:
Practice Address - Street 1:39 6TH ST
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NY
Practice Address - Zip Code:10803-1140
Practice Address - Country:US
Practice Address - Phone:914-755-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY457081101174400000X
NY457080101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist