Provider Demographics
NPI:1093019861
Name:MATTHIAS, WILLIE J (CASAC)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:J
Last Name:MATTHIAS
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-3300
Mailing Address - Country:US
Mailing Address - Phone:212-964-0128
Mailing Address - Fax:212-964-0112
Practice Address - Street 1:116 JOHN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-3300
Practice Address - Country:US
Practice Address - Phone:212-964-0128
Practice Address - Fax:212-964-0112
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17858101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)