Provider Demographics
NPI:1821664368
Name:MATTA DEMOCKO, GLADYS VANESSA
Entity Type:Individual
Prefix:DR
First Name:GLADYS
Middle Name:VANESSA
Last Name:MATTA DEMOCKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 FERNDELL ST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-7325
Mailing Address - Country:US
Mailing Address - Phone:941-224-7213
Mailing Address - Fax:
Practice Address - Street 1:2415 UNIVERSITY PKWY STE 219
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2809
Practice Address - Country:US
Practice Address - Phone:800-687-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7298103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty