Provider Demographics
NPI:1578230660
Name:MATADAMA, ALEJANDRA JACQUELINE
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:JACQUELINE
Last Name:MATADAMA
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 1:13634 LEMOLI AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7722
Mailing Address - Country:US
Mailing Address - Phone:310-702-3438
Mailing Address - Fax:
Practice Address - Street 1:12437 LEWIS ST STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4651
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4840416106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician