Healthcare Provider Details

I. General information

NPI: 1609317841
Provider Name (Legal Business Name): SOFIA MATA MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 SHAVER ST
PASADENA TX
77506-2097
US

IV. Provider business mailing address

10206 KINGSPOINT RD
HOUSTON TX
77075-3324
US

V. Phone/Fax

Practice location:
  • Phone: 281-299-6591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATC7135
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: