Healthcare Provider Details

I. General information

NPI: 1598533812
Provider Name (Legal Business Name): BRIANNA DANIELLE MATAMOROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PACIFICA STE 130
IRVINE CA
92618-7421
US

IV. Provider business mailing address

407 W IMPERIAL HWY STE H #235
BREA CA
92821
US

V. Phone/Fax

Practice location:
  • Phone: 949-431-6000
  • Fax:
Mailing address:
  • Phone: 562-217-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number137424
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: