Provider Demographics
NPI:1437338563
Name:MIRTA N. MATOS PSY.D P.A.
Entity Type:Organization
Organization Name:MIRTA N. MATOS PSY.D P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRTA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-599-1970
Mailing Address - Street 1:8249 NW 36TH ST
Mailing Address - Street 2:102
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6673
Mailing Address - Country:US
Mailing Address - Phone:305-599-1970
Mailing Address - Fax:305-599-1971
Practice Address - Street 1:8249 NW 36TH ST
Practice Address - Street 2:102
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6673
Practice Address - Country:US
Practice Address - Phone:305-599-1970
Practice Address - Fax:305-599-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6454283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
K6793AMedicare PIN