1619192325 NPI number — CAROLYN SUE MATULICH CCC-A

Table of content: CAROLYN SUE MATULICH CCC-A (NPI 1619192325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619192325 NPI number — CAROLYN SUE MATULICH CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATULICH
Provider First Name:
CAROLYN
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619192325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 NEDDHAM STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
617-630-0141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 CITYWEST BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-964-6681
Provider Business Practice Location Address Fax Number:
888-662-0859
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  80045 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 80045 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 188232602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00812640 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".




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