Provider Demographics
NPI:1083330153
Name:DULAC, MATTHEW JOSEPH (BA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:DULAC
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3343
Mailing Address - Country:US
Mailing Address - Phone:603-889-6147
Mailing Address - Fax:
Practice Address - Street 1:15 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3923
Practice Address - Country:US
Practice Address - Phone:603-889-6147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA99618201OtherNETWORK HEALTH
MA042611055OtherTAX ID
MA1004745OtherFALLON
MA1004745OtherNHP
MAM18633OtherBCBS
MA0000023532OtherBMC
MA1303287OtherMBHP