Provider Demographics
NPI:1801431150
Name:MATEO, MARYTERE (APC)
Entity type:Individual
Prefix:
First Name:MARYTERE
Middle Name:
Last Name:MATEO
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 BARBER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-3109
Mailing Address - Country:US
Mailing Address - Phone:803-479-1576
Mailing Address - Fax:
Practice Address - Street 1:1281 BARBER CREEK RD
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-3109
Practice Address - Country:US
Practice Address - Phone:803-479-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006194101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health