Provider Demographics
NPI:1700221645
Name:MATTICE, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MATTICE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 MARKSTOWN DR APT A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-9376
Mailing Address - Country:US
Mailing Address - Phone:518-364-5849
Mailing Address - Fax:
Practice Address - Street 1:359 FENN ST
Practice Address - Street 2:ADMINISTRATIVE OFFICES
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-5261
Practice Address - Country:US
Practice Address - Phone:413-629-1251
Practice Address - Fax:413-448-2198
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLSW15557101YM0800X
FL155571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health