Provider Demographics
NPI:1417656356
Name:MATOS CORDERO, MILDRED B
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:B
Last Name:MATOS CORDERO
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 1:14621 PINE GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3286
Mailing Address - Country:US
Mailing Address - Phone:813-448-8762
Mailing Address - Fax:
Practice Address - Street 1:14621 PINE GLEN CIR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-3286
Practice Address - Country:US
Practice Address - Phone:813-448-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical