Healthcare Provider Details

I. General information

NPI: 1174210322
Provider Name (Legal Business Name): MATTHEW HOTALING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10C AIRLINE DR
ALBANY NY
12205-1004
US

IV. Provider business mailing address

299 COLUMBIA ST
COHOES NY
12047-2213
US

V. Phone/Fax

Practice location:
  • Phone: 518-934-1722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number100334-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: