Provider Demographics
NPI:1518333699
Name:MATEO ANTUNA, DAISY CORAL
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:CORAL
Last Name:MATEO ANTUNA
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 1:4041 N CENTRAL AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5351
Mailing Address - Fax:
Practice Address - Street 1:4041 N CENTRAL AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3313
Practice Address - Country:US
Practice Address - Phone:602-279-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZD10847152101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1303295Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD