Provider Demographics
NPI:1407283088
Name:MATOS, AMY M (LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:MATOS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CORLISS ST STE B
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2602
Mailing Address - Country:US
Mailing Address - Phone:401-793-8400
Mailing Address - Fax:401-793-8402
Practice Address - Street 1:180 CORLISS ST STE B
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2602
Practice Address - Country:US
Practice Address - Phone:401-793-8400
Practice Address - Fax:401-793-8402
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
RIISW026621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid