Provider Demographics
NPI:1215000773
Name:MATIATOS, IRENE (PHD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:MATIATOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SILVER DARTER LN
Mailing Address - Street 2:
Mailing Address - City:BILTMORE LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9526
Mailing Address - Country:US
Mailing Address - Phone:551-206-3762
Mailing Address - Fax:828-633-2143
Practice Address - Street 1:23 SILVER DARTER LN
Practice Address - Street 2:
Practice Address - City:BILTMORE LAKE
Practice Address - State:NC
Practice Address - Zip Code:28715-9526
Practice Address - Country:US
Practice Address - Phone:551-206-3762
Practice Address - Fax:828-633-2143
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010778-1103TB0200X, 103TC0700X, 103TF0000X
NC3902103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS10778OtherWORKERS COMPENSATION
NY386523OtherMVP
NYP570970OtherOXFORD
NY6802210OtherGHI
NY386523OtherMVP