Provider Demographics
NPI:1306939913
Name:MATTHEWS, MICHAEL ROGER (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROGER
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 VALENCIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:781-981-3790
Mailing Address - Fax:866-473-2390
Practice Address - Street 1:1430 CLOVE ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:917-613-2645
Practice Address - Fax:966-473-2390
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO01695-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical