Provider Demographics
NPI:1649690991
Name:MATA, JOANNE (LPT)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:
Other - Last Name:BLUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8688 N CEDAR AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4826
Mailing Address - Country:US
Mailing Address - Phone:559-600-7180
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35103167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician