Provider Demographics
NPI:1689240178
Name:MATYSIAK, NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MATYSIAK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HARMON DR APT D
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2188
Mailing Address - Country:US
Mailing Address - Phone:413-433-0486
Mailing Address - Fax:
Practice Address - Street 1:45 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1719
Practice Address - Country:US
Practice Address - Phone:203-910-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6567235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist