MEDICARE: DIANA MICHAEL MATA MSW, LGSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker		DC

General Provider Information

NPI Number	:	1376971275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA MICHAEL MATA MSW, LGSW

Provider Business Mailing Address
First Line	:	3560 WARDER ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20010-1700
Country	:	US
Telephone Number	:	202-528-4007
Fax Number	:

Provider Business Practice Location Address
First Line	:	3560 WARDER ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20010-1700
Country	:	US
Telephone Number	:	202-528-4007
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2013
Last Update Date	:	10/31/2013

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