Provider Demographics
NPI:1528496106
Name:MATA, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
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 384
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-0384
Mailing Address - Country:US
Mailing Address - Phone:214-901-5010
Mailing Address - Fax:
Practice Address - Street 1:1111 BELT LINE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3299
Practice Address - Country:US
Practice Address - Phone:214-901-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66569101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-3211053OtherIRS TAX ID NUMBER