Provider Demographics
NPI:1083387443
Name:CUNANAN, MATTEO LORENZO
Entity Type:Individual
Prefix:
First Name:MATTEO
Middle Name:LORENZO
Last Name:CUNANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 TUOLUMNE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4641
Mailing Address - Country:US
Mailing Address - Phone:707-648-8121
Mailing Address - Fax:
Practice Address - Street 1:908 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4641
Practice Address - Country:US
Practice Address - Phone:707-648-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor