Provider Demographics
NPI:1659107399
Name:BIASETTI, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BIASETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-2118
Mailing Address - Country:US
Mailing Address - Phone:845-796-5095
Mailing Address - Fax:
Practice Address - Street 1:22 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-2118
Practice Address - Country:US
Practice Address - Phone:845-796-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1830491241103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool