Healthcare Provider Details

I. General information

NPI: 1831403658
Provider Name (Legal Business Name): MRS. BAILEY MATTISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BAILEY CLARK

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 PARK AVE
NEW YORK NY
10035-1316
US

IV. Provider business mailing address

1366 INWOOD AVE
BRONX NY
10452-3203
US

V. Phone/Fax

Practice location:
  • Phone: 646-459-6091
  • Fax:
Mailing address:
  • Phone: 702-578-3035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: