Provider Demographics
NPI:1407006976
Name:MATTIA, DOREEN ANN
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:ANN
Last Name:MATTIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782
Mailing Address - Country:US
Mailing Address - Phone:631-750-3617
Mailing Address - Fax:
Practice Address - Street 1:174 LOWELL RD
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2215
Practice Address - Country:US
Practice Address - Phone:631-750-3617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherDAY TRAINER/DEVELOPMENTAL DELAYS