Provider Demographics
NPI:1912186040
Name:MATOS, MIRTA N (PSYD11/03/)
Entity Type:Individual
Prefix:DR
First Name:MIRTA
Middle Name:N
Last Name:MATOS
Suffix:
Gender:F
Credentials:PSYD11/03/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8525 SW 92ND ST STE B8
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7374
Mailing Address - Country:US
Mailing Address - Phone:305-596-9989
Mailing Address - Fax:305-598-0220
Practice Address - Street 1:8525 SW 92ND ST STE B8
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7374
Practice Address - Country:US
Practice Address - Phone:305-596-9989
Practice Address - Fax:305-598-0220
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6454103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z2124DMedicare PIN