Provider Demographics
NPI:1669460135
Name:MIRTA MATOS PSYD PA
Entity Type:Organization
Organization Name:MIRTA MATOS PSYD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-596-9989
Mailing Address - Street 1:8525 SW 92ND ST
Mailing Address - Street 2:#B-8
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7365
Mailing Address - Country:US
Mailing Address - Phone:305-596-9989
Mailing Address - Fax:305-598-0220
Practice Address - Street 1:8525 SW 92ND ST
Practice Address - Street 2:#B-8
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7365
Practice Address - Country:US
Practice Address - Phone:305-596-9989
Practice Address - Fax:305-598-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6454103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54791OtherBCBS
K6793Medicare ID - Type Unspecified