Provider Demographics
NPI:1841019221
Name:MATAMUA, MICHAEL (BCABA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MATAMUA
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4147 SUMMIT PARK RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-1601
Mailing Address - Country:US
Mailing Address - Phone:808-277-4976
Mailing Address - Fax:
Practice Address - Street 1:2929 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1173
Practice Address - Country:US
Practice Address - Phone:505-788-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-19-10195106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst