=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255790283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ARIANA MATTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 02/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 S 6TH ST
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88210-2079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-746-3585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 706 WINGED FOOT DR
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88220-9253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-302-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 5917
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------