Provider Demographics
NPI:1831462811
Name:MATA, GAVIN-JOHN K
Entity Type:Individual
Prefix:
First Name:GAVIN-JOHN
Middle Name:K
Last Name:MATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 PULIMA DR
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1331
Mailing Address - Country:US
Mailing Address - Phone:808-961-5166
Mailing Address - Fax:
Practice Address - Street 1:2706 PULIMA DR
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-1331
Practice Address - Country:US
Practice Address - Phone:808-961-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor