MEDICARE: ELISELDA MATA LPC, CAC III

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	15407	CO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	7115	CO

General Provider Information

NPI Number	:	1720324106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISELDA MATA LPC, CAC III

Provider Business Mailing Address
First Line	:	2851 S PARKER RD STE 410
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80014-2725
Country	:	US
Telephone Number	:	720-524-6874
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 N EMERSON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-5127
Country	:	US
Telephone Number	:	970-424-4061
Fax Number	:	872-766-0965

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

Provider Enumeration Date	:	12/12/2012
Last Update Date	:	10/11/2023

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