Provider Demographics
NPI:1265896831
Name:MATOS, VILMA E, (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:VILMA
Middle Name:E,
Last Name:MATOS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MS
Other - First Name:VILMA
Other - Middle Name:
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:39 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2232
Mailing Address - Country:US
Mailing Address - Phone:631-807-2822
Mailing Address - Fax:631-262-0823
Practice Address - Street 1:39 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-2232
Practice Address - Country:US
Practice Address - Phone:631-807-2822
Practice Address - Fax:631-262-0823
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR026711-11041C0700X
NY9464359911041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool