Provider Demographics
NPI:1144789181
Name:MATTHEWS, TAQUORYIEA
Entity Type:Individual
Prefix:
First Name:TAQUORYIEA
Middle Name:
Last Name:MATTHEWS
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 1:23157 IRONWOOD AVE APT 28
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-8037
Mailing Address - Country:US
Mailing Address - Phone:714-422-8279
Mailing Address - Fax:
Practice Address - Street 1:23157 IRONWOOD AVE APT 28
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-8037
Practice Address - Country:US
Practice Address - Phone:714-422-8279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95462229E51258Medicaid