Provider Demographics
NPI:1407220205
Name:MATSUDA, KOZUE
Entity Type:Individual
Prefix:
First Name:KOZUE
Middle Name:
Last Name:MATSUDA
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 1:4615 CENTER BLVD
Mailing Address - Street 2:APT 1604
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5738
Mailing Address - Country:US
Mailing Address - Phone:917-599-6033
Mailing Address - Fax:
Practice Address - Street 1:4615 CENTER BLVD
Practice Address - Street 2:APT 1604
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11109-5738
Practice Address - Country:US
Practice Address - Phone:917-599-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000841103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst