Provider Demographics
NPI:1275204778
Name:KILLIAN, MATTHEW G (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:G
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 APPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7214
Mailing Address - Country:US
Mailing Address - Phone:732-939-6463
Mailing Address - Fax:
Practice Address - Street 1:200 BROADHOLLOW RD STE 119
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4846
Practice Address - Country:US
Practice Address - Phone:516-588-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403593363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health