Provider Demographics
NPI:1639415300
Name:MATOCHA, THERESA MARIE (LISCW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:MATOCHA
Suffix:
Gender:F
Credentials:LISCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 HUBBARD LN
Mailing Address - Street 2:STE 7
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4803
Mailing Address - Country:US
Mailing Address - Phone:802-349-2202
Mailing Address - Fax:
Practice Address - Street 1:3015 HUBBARD LN
Practice Address - Street 2:STE 7
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4803
Practice Address - Country:US
Practice Address - Phone:802-425-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.0089650101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT089.0089650OtherSTATE OF VT