Provider Demographics
NPI:1013403823
Name:MATUTE, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MATUTE
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 1:4300 N UNIVERSITY DR STE F100
Mailing Address - Street 2:STE F-100 #A117
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6243
Mailing Address - Country:US
Mailing Address - Phone:561-961-8785
Mailing Address - Fax:
Practice Address - Street 1:1000 N HIATUS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3097
Practice Address - Country:US
Practice Address - Phone:954-333-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FL19497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty