Provider Demographics
NPI:1669032785
Name:MATIAS, YATZMELI
Entity type:Individual
Prefix:
First Name:YATZMELI
Middle Name:
Last Name:MATIAS
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:RR 02 BUZON 3390
Mailing Address - Street 2:
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610
Mailing Address - Country:US
Mailing Address - Phone:787-672-0813
Mailing Address - Fax:
Practice Address - Street 1:CALLE BRUMBAUGH #1162
Practice Address - Street 2:URB. GARCIA UBARRI
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925
Practice Address - Country:US
Practice Address - Phone:787-753-9437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7019103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program