Provider Demographics
NPI:1023725470
Name:MATA, SYDNEY
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:MATA
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 1:3815 E. MAIN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174
Mailing Address - Country:US
Mailing Address - Phone:630-584-7530
Mailing Address - Fax:630-584-7762
Practice Address - Street 1:3815 E. MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:630-584-7762
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-242237106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician