Provider Demographics
NPI:1801331640
Name:MATUSIAK, ANDREW JAMES
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:MATUSIAK
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 1:143 PINE HILL RD
Mailing Address - Street 2:UNIT 17A
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1955
Mailing Address - Country:US
Mailing Address - Phone:860-921-8909
Mailing Address - Fax:
Practice Address - Street 1:143 PINE HILL RD
Practice Address - Street 2:UNIT 17A
Practice Address - City:THOMASTON
Practice Address - State:CT
Practice Address - Zip Code:06787-1955
Practice Address - Country:US
Practice Address - Phone:860-921-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104941041C0700X
CT32491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty