Healthcare Provider Details

I. General information

NPI: 1104751064
Provider Name (Legal Business Name): CARLY IRENE MATTICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 DOMINION WAY STE 101
COLORADO SPRINGS CO
80918-1464
US

IV. Provider business mailing address

4343 WOMACK DR
COLORADO SPRINGS CO
80915-2721
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-7428
  • Fax:
Mailing address:
  • Phone: 719-418-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: