Provider Demographics
NPI:1912447384
Name:MATOS, ANGELA ROSE (LPC CANDIDATE)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:ROSE
Last Name:MATOS
Suffix:
Gender:F
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:ROSE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20200 N HARRAH RD
Mailing Address - Street 2:
Mailing Address - City:LUTHER
Mailing Address - State:OK
Mailing Address - Zip Code:73054-9707
Mailing Address - Country:US
Mailing Address - Phone:405-818-5049
Mailing Address - Fax:
Practice Address - Street 1:500 N MERIDIAN AVE STE 406
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-5755
Practice Address - Country:US
Practice Address - Phone:405-818-5049
Practice Address - Fax:833-597-8370
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200695330AMedicaid