Provider Demographics
NPI:1619403300
Name:MATA, NADINE P (BA, LCDC, QMHP-CS)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:P
Last Name:MATA
Suffix:
Gender:F
Credentials:BA, LCDC, QMHP-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13175 WESLEYAN AVE
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-2126
Mailing Address - Country:US
Mailing Address - Phone:432-294-4575
Mailing Address - Fax:
Practice Address - Street 1:13175 WESLEYAN AVE
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-2126
Practice Address - Country:US
Practice Address - Phone:432-294-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11556101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)