MEDICARE: MRS. BAILEY MATTISON

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	225400000X	Rehabilitation Practitioner
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1831403658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BAILEY MATTISON

Provider Business Mailing Address
First Line	:	1366 INWOOD AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10452-3203
Country	:	US
Telephone Number	:	702-578-3035
Fax Number	:

Provider Business Practice Location Address
First Line	:	1841 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1316
Country	:	US
Telephone Number	:	646-459-6091
Fax Number	:

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

Provider Enumeration Date	:	08/04/2010
Last Update Date	:	08/23/2016

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