Healthcare Provider Details

I. General information

NPI: 1548633787
Provider Name (Legal Business Name): ANYSSA MATATALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 LAKEWOOD RANCH BLVD
LAKEWOOD RANCH FL
34202-4237
US

IV. Provider business mailing address

8220 LAKEWOOD RANCH BLVD UNIT 210
LAKEWOOD RANCH FL
34202-5264
US

V. Phone/Fax

Practice location:
  • Phone: 603-553-7066
  • Fax:
Mailing address:
  • Phone: 321-961-3489
  • Fax: 407-386-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: