Provider Demographics
NPI:1669194361
Name:ROBINSON, MATTEARA
Entity type:Individual
Prefix:
First Name:MATTEARA
Middle Name:
Last Name:ROBINSON
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 1:1104 FIELD ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46320-2659
Mailing Address - Country:US
Mailing Address - Phone:219-614-3591
Mailing Address - Fax:
Practice Address - Street 1:1104 FIELD ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2659
Practice Address - Country:US
Practice Address - Phone:219-614-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22-015762-1253Z00000X
IN23-015762-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN88-1746706Medicaid