Provider Demographics
NPI:1124338843
Name:COLONNA, MATTHEW LAWRENCE III (LICSW)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LAWRENCE
Last Name:COLONNA
Suffix:III
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CITYVIEW LAVE UNIT # 611
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4678
Mailing Address - Country:US
Mailing Address - Phone:908-247-7721
Mailing Address - Fax:
Practice Address - Street 1:32 HAMILTON STREET
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757
Practice Address - Country:US
Practice Address - Phone:508-634-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1157771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical