Provider Demographics
NPI:1497566756
Name:MATIS, REBECCA MAE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAE
Last Name:MATIS
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 1:618 E BROADWAY DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1428
Mailing Address - Country:US
Mailing Address - Phone:701-317-3011
Mailing Address - Fax:
Practice Address - Street 1:380 POLK ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1623
Practice Address - Country:US
Practice Address - Phone:317-888-1557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-406256106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician