Provider Demographics
NPI:1619192325
Name:MATULICH, CAROLYN SUE (CCC-A)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:MATULICH
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NEDDHAM STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:2500 CITYWEST BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-3000
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80045237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188232602Medicaid
P00812640OtherRAILROAD
TX8L13394Medicare PIN