Healthcare Provider Details

I. General information

NPI: 1821905381
Provider Name (Legal Business Name): GISELLE MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 PINN RD
LYTLE TX
78052-3810
US

IV. Provider business mailing address

117 PINN RD
LYTLE TX
78052-3810
US

V. Phone/Fax

Practice location:
  • Phone: 210-823-3945
  • Fax:
Mailing address:
  • Phone: 210-823-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number99961
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: