Provider Demographics
NPI:1619222486
Name:MATOS CORREA, CAROLL
Entity Type:Individual
Prefix:
First Name:CAROLL
Middle Name:
Last Name:MATOS CORREA
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 1:13211 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5110
Mailing Address - Country:US
Mailing Address - Phone:718-216-8341
Mailing Address - Fax:
Practice Address - Street 1:13211 58TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5110
Practice Address - Country:US
Practice Address - Phone:718-216-8341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator