Provider Demographics
NPI:1326722687
Name:MATOS RODRIGUEZ, MARIELA LISVETTE
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:LISVETTE
Last Name:MATOS RODRIGUEZ
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 1:2002 AGATE DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4916
Mailing Address - Country:US
Mailing Address - Phone:254-630-9426
Mailing Address - Fax:
Practice Address - Street 1:2300 CLEAR CREEK RD STE 103
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4985
Practice Address - Country:US
Practice Address - Phone:254-768-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst