Provider Demographics
NPI:1588900179
Name:MATA, BREYE (LMFT130674)
Entity type:Individual
Prefix:
First Name:BREYE
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:LMFT130674
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3413
Mailing Address - Country:US
Mailing Address - Phone:323-953-7350
Mailing Address - Fax:323-661-5046
Practice Address - Street 1:3910 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3413
Practice Address - Country:US
Practice Address - Phone:323-953-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT130674106H00000X
CA78100106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist