Provider Demographics
NPI:1023489804
Name:MATA, MIGUELINA
Entity type:Individual
Prefix:
First Name:MIGUELINA
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 1:38 BROWNS AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-1505
Mailing Address - Country:US
Mailing Address - Phone:781-842-1212
Mailing Address - Fax:
Practice Address - Street 1:50 REDFIELD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3630
Practice Address - Country:US
Practice Address - Phone:617-288-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health