Provider Demographics
NPI:1053768572
Name:MATA, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
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 1:520 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2769
Mailing Address - Country:US
Mailing Address - Phone:617-516-5733
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:617-516-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100009651281OtherNEIGHBORHOOD HEALTH PLAN