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General NPI Number Information
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NPI Number | 1477380368
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Entity Type | Individual
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Provider Name | MARISSA MATA LPC
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Gender | Female
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Dates
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Enumeration Date | 09/16/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 5788 ECKHERT RD
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City | SAN ANTONIO
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State | TX
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Zip | 78240-3900
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Country | US
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Telephone | 210-450-6450
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Fax |
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Provider Business Mailing Address
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Address Line | 8436 WOODCLIFF BLVD
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City | SELMA
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State | TX
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Zip | 78154-3336
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 88864
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 88864
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License Number State | TX
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