Healthcare Provider Details

I. General information

NPI: 1801431150
Provider Name (Legal Business Name): MARYTERE MATEO APC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1281 BARBER CREEK RD
STATHAM GA
30666-3109
US

IV. Provider business mailing address

1281 BARBER CREEK RD
STATHAM GA
30666-3109
US

V. Phone/Fax

Practice location:
  • Phone: 803-479-1576
  • Fax:
Mailing address:
  • Phone: 803-479-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC006194
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC006194
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC006194
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: