Provider Demographics
NPI:1194477901
Name:MATTOX, TIARA
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:MATTOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CASALS PL APT 13C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-3138
Mailing Address - Country:US
Mailing Address - Phone:917-639-8277
Mailing Address - Fax:
Practice Address - Street 1:120 CASALS PL APT 13C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-3138
Practice Address - Country:US
Practice Address - Phone:917-639-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000000Medicaid