Provider Demographics
NPI:1023291952
Name:JOHN, JOHN MATTATHIL (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MATTATHIL
Last Name:JOHN
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 1:185 MONTAGUE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3608
Mailing Address - Country:US
Mailing Address - Phone:718-222-1701
Mailing Address - Fax:718-222-1474
Practice Address - Street 1:185 MONTAGUE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3608
Practice Address - Country:US
Practice Address - Phone:718-222-1701
Practice Address - Fax:718-222-1474
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0492361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical