Provider Demographics
NPI:1417529819
Name:MATOS, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:MATOS
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:PO BOX 1750
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-1750
Mailing Address - Country:US
Mailing Address - Phone:787-923-1424
Mailing Address - Fax:
Practice Address - Street 1:LA FLORESTA
Practice Address - Street 2:742
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-923-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR05940103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist