Provider Demographics
NPI:1144770637
Name:MATTHEWS, ANGELA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:SEASON
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-2778
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MT. BELVEDERE BLVD
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-774-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092018104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker