Provider Demographics
NPI:1275830952
Name:MATUSIEWICZ, DANIEL EDWARD (THM)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:EDWARD
Last Name:MATUSIEWICZ
Suffix:
Gender:M
Credentials:THM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DEY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3571
Mailing Address - Country:US
Mailing Address - Phone:607-257-6320
Mailing Address - Fax:607-273-6442
Practice Address - Street 1:201 DEY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3571
Practice Address - Country:US
Practice Address - Phone:607-257-6320
Practice Address - Fax:607-273-6442
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health