Provider Demographics
NPI:1235483058
Name:DE LA MATA, KRISTINA A
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:A
Last Name:DE LA MATA
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:G2 CALLE 7
Mailing Address - Street 2:URBANIZACION EL MIRADOR
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-7578
Mailing Address - Country:US
Mailing Address - Phone:787-406-9322
Mailing Address - Fax:
Practice Address - Street 1:22 CALLE GONZALEZ GIUSTI STE 208
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-3011
Practice Address - Country:US
Practice Address - Phone:787-406-9322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist