Provider Demographics
NPI:1356465132
Name:MATTA, MARY ANN (RN, SWT, CACR)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:MATTA
Suffix:
Gender:F
Credentials:RN, SWT, CACR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6181 DAKOTA CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1565
Mailing Address - Country:US
Mailing Address - Phone:248-227-4279
Mailing Address - Fax:248-543-0017
Practice Address - Street 1:2710 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1630
Practice Address - Country:US
Practice Address - Phone:248-543-1090
Practice Address - Fax:248-543-0017
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803074335101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)