Provider Demographics
NPI:1912211087
Name:MATA, RAQUEL (LMT)
Entity Type:Individual
Prefix:MS
First Name:RAQUEL
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6290 W SAMPLE RD
Mailing Address - Street 2:102
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3101
Mailing Address - Country:US
Mailing Address - Phone:954-757-2939
Mailing Address - Fax:
Practice Address - Street 1:6290 W SAMPLE RD
Practice Address - Street 2:102
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-3101
Practice Address - Country:US
Practice Address - Phone:954-757-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-01
Last Update Date:2010-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL57982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist