Healthcare Provider Details

I. General information

NPI: 1043907462
Provider Name (Legal Business Name): MATILDE AYBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 COMMERCE CENTER DR
SAINT CLOUD FL
34769-1549
US

IV. Provider business mailing address

2950 SAN JUAN CIR APT 133
KISSIMMEE FL
34746-4894
US

V. Phone/Fax

Practice location:
  • Phone: 407-450-5985
  • Fax:
Mailing address:
  • Phone: 407-288-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH21287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: