Provider Demographics
NPI:1508436577
Name:MATOS DELGADO, MARCO ANDRE
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ANDRE
Last Name:MATOS DELGADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3917
Mailing Address - Country:US
Mailing Address - Phone:415-229-0500
Mailing Address - Fax:
Practice Address - Street 1:2919 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3917
Practice Address - Country:US
Practice Address - Phone:415-229-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA139107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program