Provider Demographics
NPI:1790346351
Name:MATITYAHU, SAMARA (LCAT-LIMITED PERMIT)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:MATITYAHU
Suffix:
Gender:F
Credentials:LCAT-LIMITED PERMIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E 14TH ST FRNT 1E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4111
Mailing Address - Country:US
Mailing Address - Phone:646-770-7180
Mailing Address - Fax:
Practice Address - Street 1:315 WYCKOFF AVE STE 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5842
Practice Address - Country:US
Practice Address - Phone:718-497-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health