Provider Demographics
NPI:1497494694
Name:MATA, ALLYSON KRYSTINE (BHS II)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:KRYSTINE
Last Name:MATA
Suffix:
Gender:F
Credentials:BHS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10281 KIDD ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3469
Mailing Address - Country:US
Mailing Address - Phone:951-715-5050
Mailing Address - Fax:
Practice Address - Street 1:10281 KIDD ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3469
Practice Address - Country:US
Practice Address - Phone:951-715-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WPLGQV175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist