Provider Demographics
NPI:1164136347
Name:MATTA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MATTA
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 1:1005 14TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-7452
Mailing Address - Country:US
Mailing Address - Phone:281-908-8980
Mailing Address - Fax:
Practice Address - Street 1:14280 E JEWELL AVE STE B
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-7939
Practice Address - Country:US
Practice Address - Phone:303-214-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician