MEDICARE: JONATHAN C MATOS MA COUNSELING

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	101YP2500X	Professional Counselor	A18188	NC

General Provider Information

NPI Number	:	1629785266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN C MATOS MA COUNSELING

Provider Business Mailing Address
First Line	:	6443 BURLWOOD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-5603
Country	:	US
Telephone Number	:	980-275-0143
Fax Number	:

Provider Business Practice Location Address
First Line	:	3646 CENTRAL AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6064
Country	:	US
Telephone Number	:	704-910-5810
Fax Number	:

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

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	11/02/2022

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