Healthcare Provider Details

I. General information

NPI: 1396081170
Provider Name (Legal Business Name): GUSTAVO MATOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2012
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 W PALMETTO RD STE 600
BOCA RATON FL
33433
US

IV. Provider business mailing address

4620 N STATE ROAD 7 STE 300
LAUDERDALE LAKES FL
33319-5867
US

V. Phone/Fax

Practice location:
  • Phone: 877-535-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: