Provider Demographics
NPI:1700200201
Name:MATA, BETHANY AWBREY (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:AWBREY
Last Name:MATA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:BETHANY
Other - Middle Name:AWBREY
Other - Last Name:ROMERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:440 RAYNOLDS ST # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-215-5700
Practice Address - Fax:915-215-8872
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83064133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered