Provider Demographics
NPI:1679878771
Name:MATTEO R MUTI,JR
Entity Type:Organization
Organization Name:MATTEO R MUTI,JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRE4SIDENT/PSYCHOLOIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTEO
Authorized Official - Middle Name:RENATO
Authorized Official - Last Name:MUTI
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-763-1212
Mailing Address - Street 1:12214 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3830
Mailing Address - Country:US
Mailing Address - Phone:818-763-1212
Mailing Address - Fax:
Practice Address - Street 1:12214 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3830
Practice Address - Country:US
Practice Address - Phone:818-763-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA004454251K00000X, 251S00000X
CAZP173251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP004454Medicare UPIN