Provider Demographics
NPI:1932503984
Name:MATA, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANA
Other - Middle Name:
Other - Last Name:MATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12169 COOK RD
Mailing Address - Street 2:
Mailing Address - City:GAINES
Mailing Address - State:MI
Mailing Address - Zip Code:48436-9617
Mailing Address - Country:US
Mailing Address - Phone:810-610-7732
Mailing Address - Fax:
Practice Address - Street 1:12169 COOK RD
Practice Address - Street 2:
Practice Address - City:GAINES
Practice Address - State:MI
Practice Address - Zip Code:48436-9617
Practice Address - Country:US
Practice Address - Phone:810-610-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor