Provider Demographics
NPI:1508400961
Name:MATONDO, AIYANA AMARIS (COTA)
Entity Type:Individual
Prefix:
First Name:AIYANA
Middle Name:AMARIS
Last Name:MATONDO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HUDSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553
Mailing Address - Country:US
Mailing Address - Phone:201-566-6429
Mailing Address - Fax:
Practice Address - Street 1:105 STEVENS AVENUE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550
Practice Address - Country:US
Practice Address - Phone:914-668-4238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009716-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant