Provider Demographics
NPI:1790429413
Name:MATA, TAYLAH
Entity type:Individual
Prefix:
First Name:TAYLAH
Middle Name:
Last Name:MATA
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:JAL
Mailing Address - State:NM
Mailing Address - Zip Code:88252-0357
Mailing Address - Country:US
Mailing Address - Phone:575-552-5029
Mailing Address - Fax:
Practice Address - Street 1:24 SANDY LANE
Practice Address - Street 2:
Practice Address - City:JAL
Practice Address - State:NM
Practice Address - Zip Code:88252
Practice Address - Country:US
Practice Address - Phone:575-552-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician