Provider Demographics
NPI:1366120412
Name:MATURO, ILEANA ROSE
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:ROSE
Last Name:MATURO
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 1:2294 OLD POST RD N
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9559
Mailing Address - Country:US
Mailing Address - Phone:845-705-4923
Mailing Address - Fax:
Practice Address - Street 1:20 CORPORATE WOODS BLVD STE 209
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2503
Practice Address - Country:US
Practice Address - Phone:518-213-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health