Healthcare Provider Details

I. General information

NPI: 1295414951
Provider Name (Legal Business Name): NICOLE MARIE MATOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 HWY 116 N
SEBASTOPOL CA
95472-2607
US

IV. Provider business mailing address

19765 HIGHWAY 116
MONTE RIO CA
95462-9718
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7300
  • Fax:
Mailing address:
  • Phone: 415-602-6704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number161610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: