MEDICARE: DR. MARISSA SIMONA MATTA PHD, MHC-P, NCC, CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1810112401	NY

General Provider Information

NPI Number	:	1225699440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISSA SIMONA MATTA PHD, MHC-P, NCC, CRC

Provider Business Mailing Address
First Line	:	1775 E 18TH ST APT 3C
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2110
Country	:	US
Telephone Number	:	718-207-3730
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 BROADWAY FL 5
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10018-1905
Country	:	US
Telephone Number	:	718-207-3730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	06/27/2019

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