Healthcare Provider Details

I. General information

NPI: 1033532551
Provider Name (Legal Business Name): HEATHER MATURO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 4TH ST N STE 240A
ST PETERSBURG FL
33716-2918
US

IV. Provider business mailing address

11300 4TH ST N STE 240A
ST PETERSBURG FL
33716-2918
US

V. Phone/Fax

Practice location:
  • Phone: 219-508-2465
  • Fax:
Mailing address:
  • Phone: 219-508-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberMH12745
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12745
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: