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General NPI Number Information
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NPI Number | 1912420548
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Entity Type | Individual
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Provider Name | REBECA EVORA MATOZINHO M.S., BCBS, DTLLP
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Gender | Female
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Dates
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Enumeration Date | 07/25/2017
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Last Update Date | 07/03/2024
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Provider Practice Location Address
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Address Line | 4211 PARKWAY PLACE DR SW
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City | GRANDVILLE
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State | MI
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Zip | 49418-2695
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Country | US
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Telephone | 616-222-3700
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Fax |
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Provider Business Mailing Address
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Address Line | 300 68TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-6927
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Country | US
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Telephone | 616-455-5000
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-22-62853
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License Number State | FL
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