Provider Demographics
NPI:1790525483
Name:MATOS-MERCADO, DALLY
Entity type:Individual
Prefix:
First Name:DALLY
Middle Name:
Last Name:MATOS-MERCADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DALLY
Other - Middle Name:
Other - Last Name:MATOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:43 S RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-5420
Mailing Address - Country:US
Mailing Address - Phone:425-458-8525
Mailing Address - Fax:
Practice Address - Street 1:550 BROAD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4537
Practice Address - Country:US
Practice Address - Phone:201-822-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker