Provider Demographics
NPI:1790298784
Name:MATIYA, MICHELLE CATHERINE (EDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CATHERINE
Last Name:MATIYA
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:CATHERINE
Other - Last Name:OBRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:6000 W RAYFORD RD APT 5208
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-2221
Mailing Address - Country:US
Mailing Address - Phone:845-321-1813
Mailing Address - Fax:
Practice Address - Street 1:6000 W RAYFORD RD APT 5208
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-2221
Practice Address - Country:US
Practice Address - Phone:845-321-1813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9504039103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool