Provider Demographics
NPI:1821128661
Name:MATAKA, JOHN RICHARD (RAS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:MATAKA
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 WILSON STREET
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363
Mailing Address - Country:US
Mailing Address - Phone:209-567-4151
Mailing Address - Fax:209-567-4112
Practice Address - Street 1:1904 RICHLAND AVE BLDG F
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-525-7411
Practice Address - Fax:209-541-2083
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC5651214101YA0400X
CAM0412211519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)