Basic Information
| Provider Information | |||||||||
| NPI: | 1295941839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4273 FOXRUN DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHINO HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096065608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2008 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW 12000 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.