Provider Demographics
NPI:1982911285
Name:MATTU, ALI (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:MATTU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 BROADWAY STE 1425
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1916
Mailing Address - Country:US
Mailing Address - Phone:212-246-5792
Mailing Address - Fax:
Practice Address - Street 1:3 COLUMBUS CIRCLE, SUITE 1425
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1903
Practice Address - Country:US
Practice Address - Phone:212-246-5744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical