Healthcare Provider Details

I. General information

NPI: 1093231821
Provider Name (Legal Business Name): ANDREA MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 N TELSHOR BLVD STE C
LAS CRUCES NM
88011-8201
US

IV. Provider business mailing address

4650 MELROSE RD
LAS CRUCES NM
88011-4372
US

V. Phone/Fax

Practice location:
  • Phone: 575-405-2351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11060
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: