Provider Demographics
NPI:1225699440
Name:MATTA, MARISSA SIMONA (PHD, MHC-P, NCC, CRC)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:SIMONA
Last Name:MATTA
Suffix:
Gender:F
Credentials:PHD, MHC-P, NCC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 E 18TH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2110
Mailing Address - Country:US
Mailing Address - Phone:718-207-3730
Mailing Address - Fax:
Practice Address - Street 1:1441 BROADWAY FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-1905
Practice Address - Country:US
Practice Address - Phone:718-207-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1810112401101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty