Healthcare Provider Details

I. General information

NPI: 1144178435
Provider Name (Legal Business Name): AVA ELYSE MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 E BROADWAY ST
MT PLEASANT MI
48858-2933
US

IV. Provider business mailing address

7785 HOSPITAL RD
FREELAND MI
48623-8610
US

V. Phone/Fax

Practice location:
  • Phone: 989-854-8334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: