Provider Demographics
NPI:1508654450
Name:MATA, SHANTAL
Entity type:Individual
Prefix:
First Name:SHANTAL
Middle Name:
Last Name:MATA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 CONLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1509
Mailing Address - Country:US
Mailing Address - Phone:719-243-7866
Mailing Address - Fax:
Practice Address - Street 1:2385 CONLEY BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1509
Practice Address - Country:US
Practice Address - Phone:719-243-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter