Provider Demographics
NPI:1376274688
Name:SURACE, MATTHEW
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:SURACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WOLFPIT AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851
Mailing Address - Country:US
Mailing Address - Phone:203-505-5987
Mailing Address - Fax:
Practice Address - Street 1:100 WOLFPIT AVE
Practice Address - Street 2:APT 1
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851
Practice Address - Country:US
Practice Address - Phone:203-505-5987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst