Healthcare Provider Details

I. General information

NPI: 1366062101
Provider Name (Legal Business Name): MIGUEL MATEO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 FRELINGHUYSEN AVE
NEWARK NJ
07114-1349
US

IV. Provider business mailing address

2013 PRINCESS CT # 2013
WOODBRIDGE NJ
07095-3800
US

V. Phone/Fax

Practice location:
  • Phone: 973-799-0508
  • Fax:
Mailing address:
  • Phone: 908-380-7065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberNJDCATEMP
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: