Provider Demographics
NPI:1083418511
Name:MATA, ERIC (LSW, LCDCIII)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:MATA
Suffix:
Gender:
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502
Mailing Address - Country:US
Mailing Address - Phone:937-284-0744
Mailing Address - Fax:
Practice Address - Street 1:106 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502
Practice Address - Country:US
Practice Address - Phone:937-284-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161754101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)