Provider Demographics
NPI:1659531242
Name:MATICHAK, PHYLLIS MARIE (LCADC PENDING)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:MARIE
Last Name:MATICHAK
Suffix:
Gender:F
Credentials:LCADC PENDING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HANOVER AVE FL 1
Mailing Address - Street 2:SAINT CLARE'S BEHAVIORAL HEALTH CENTER
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-2020
Mailing Address - Country:US
Mailing Address - Phone:973-401-2170
Mailing Address - Fax:973-401-2183
Practice Address - Street 1:100 E HANOVER AVE FL 1
Practice Address - Street 2:SAINT CLARE'S BEHAVIORAL HEALTH CENTER
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-2020
Practice Address - Country:US
Practice Address - Phone:973-401-2170
Practice Address - Fax:973-401-2183
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJLCADC PENDING101YA0400X
NJNOT LICENSED101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health