Provider Demographics
NPI:1225801384
Name:MATAMOROS SANTOS, ITZEL CITLALLI (MS)
Entity Type:Individual
Prefix:
First Name:ITZEL
Middle Name:CITLALLI
Last Name:MATAMOROS SANTOS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 CHESWICK CT APT 2
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-7450
Mailing Address - Country:US
Mailing Address - Phone:414-369-0137
Mailing Address - Fax:
Practice Address - Street 1:19215 SE 34TH ST # 106-220
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8829
Practice Address - Country:US
Practice Address - Phone:414-369-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5383-154235Z00000X
WALL61483039235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist