Provider Demographics
NPI:1407696685
Name:MATHEW, TINA SUSAN
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:SUSAN
Last Name:MATHEW
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 1:37 APRIL LN
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-3405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 OLD ORANGEBURG RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1157
Practice Address - Country:US
Practice Address - Phone:845-680-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687630163WP0809X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult