Provider Demographics
NPI:1548633787
Name:MATATALL, ANYSSA
Entity type:Individual
Prefix:
First Name:ANYSSA
Middle Name:
Last Name:MATATALL
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 1:8220 LAKEWOOD RANCH BLVD UNIT 210
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5264
Mailing Address - Country:US
Mailing Address - Phone:321-961-3489
Mailing Address - Fax:407-386-6062
Practice Address - Street 1:8220 LAKEWOOD RANCH BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-4237
Practice Address - Country:US
Practice Address - Phone:603-553-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist