Provider Demographics
NPI:1518747542
Name:MATAMOROS MAS, MILADYS D
Entity Type:Individual
Prefix:
First Name:MILADYS
Middle Name:D
Last Name:MATAMOROS MAS
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 1:4200 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4801
Mailing Address - Country:US
Mailing Address - Phone:786-366-8145
Mailing Address - Fax:
Practice Address - Street 1:4200 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4801
Practice Address - Country:US
Practice Address - Phone:786-366-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-129817106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty