Provider Demographics
NPI:1568541472
Name:MATAMOROS, MARCELO MITCHELL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARCELO
Middle Name:MITCHELL
Last Name:MATAMOROS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5068 W PLANO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4409
Mailing Address - Country:US
Mailing Address - Phone:214-348-5325
Mailing Address - Fax:
Practice Address - Street 1:5068 W PLANO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4409
Practice Address - Country:US
Practice Address - Phone:214-348-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S98JOtherBLUE CROSS BLUE SHIELD