Provider Demographics
NPI:1831403658
Name:MATTISON, BAILEY
Entity type:Individual
Prefix:MRS
First Name:BAILEY
Middle Name:
Last Name:MATTISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1366 INWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-3203
Mailing Address - Country:US
Mailing Address - Phone:702-578-3035
Mailing Address - Fax:
Practice Address - Street 1:1841 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1316
Practice Address - Country:US
Practice Address - Phone:646-459-6091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner