Provider Demographics
NPI:1235483611
Name:MATA, KRISTAL
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTAL
Other - Middle Name:
Other - Last Name:BOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3546
Mailing Address - Country:US
Mailing Address - Phone:509-575-4084
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:509-575-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60301381101YM0800X
WALH60542509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health