MEDICARE: MRS. DAMARIS FELICIA MATA SR. RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1407350531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DAMARIS FELICIA MATA SR. RBT

Provider Business Mailing Address
First Line	:	1331 SW 104TH PSGE APT 108
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-3827
Country	:	US
Telephone Number	:	850-252-0277
Fax Number	:

Provider Business Practice Location Address
First Line	:	1331 SW 104TH PSGE APT 108
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-3827
Country	:	US
Telephone Number	:	850-252-0277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	04/24/2018

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