Provider Demographics
NPI:1487119939
Name:MATAVAO, KARINA NICOLE
Entity type:Individual
Prefix:
First Name:KARINA
Middle Name:NICOLE
Last Name:MATAVAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KARINA
Other - Middle Name:NICOLE
Other - Last Name:MCCALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3511 102ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9821
Mailing Address - Country:US
Mailing Address - Phone:425-422-3892
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health