Provider Demographics
NPI:1336619535
Name:MATA, KARLA KRISTEL
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:KRISTEL
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 1:2129 SANTA ANA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3263
Mailing Address - Country:US
Mailing Address - Phone:707-315-5307
Mailing Address - Fax:
Practice Address - Street 1:2351 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3558
Practice Address - Country:US
Practice Address - Phone:917-862-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty