Provider Demographics
NPI:1659677888
Name:MATA, ROXANNE MARIE (AMFT)
Entity Type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:MARIE
Last Name:MATA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ANGELES VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1648
Mailing Address - Country:US
Mailing Address - Phone:323-295-4555
Mailing Address - Fax:
Practice Address - Street 1:5300 ANGELES VISTA BLVD
Practice Address - Street 2:
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90043-1648
Practice Address - Country:US
Practice Address - Phone:323-295-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-05
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 171M00000X, 225400000X, 390200000X
CA129867106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program