Provider Demographics
NPI:1790436855
Name:MATOS, AMANDA INES (MA, LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:INES
Last Name:MATOS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 HILLCREST RD # B123
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1525
Mailing Address - Country:US
Mailing Address - Phone:469-206-9285
Mailing Address - Fax:
Practice Address - Street 1:12720 HILLCREST RD STE 106
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-7121
Practice Address - Country:US
Practice Address - Phone:469-206-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional