Basic Information
Provider Information | |||||||||
NPI: | 1760865562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEMATTEO | ||||||||
FirstName: | ALYSSA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5 CLARA DR | ||||||||
Address2: |   | ||||||||
City: | NORWALK | ||||||||
State: | CT | ||||||||
PostalCode: | 068513203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032463378 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 435 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ANSONIA | ||||||||
State: | CT | ||||||||
PostalCode: | 064011964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009892676 | ||||||||
FaxNumber: | 8457046178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2015 | ||||||||
LastUpdateDate: | 07/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 4788 | CT | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 01420795 | 05 | NY |   | MEDICAID |