Provider Demographics
NPI:1841804713
Name:TICE, MATTHEW A (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:TICE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1573
Mailing Address - Country:US
Mailing Address - Phone:267-592-5711
Mailing Address - Fax:
Practice Address - Street 1:50 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-4022
Practice Address - Country:US
Practice Address - Phone:716-892-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1321171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical