Provider Demographics
NPI:1184441941
Name:MATANOS, KLARISSA
Entity type:Individual
Prefix:
First Name:KLARISSA
Middle Name:
Last Name:MATANOS
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:G3230 BEECHER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3604
Mailing Address - Country:US
Mailing Address - Phone:810-342-5656
Mailing Address - Fax:
Practice Address - Street 1:G3230 BEECHER RD STE 1
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3604
Practice Address - Country:US
Practice Address - Phone:810-342-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2025-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical