Provider Demographics
NPI:1124685359
Name:MATOS, JOSE GIL (LISW-S)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:GIL
Last Name:MATOS
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 MARINERS CIR APT E
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-3006
Mailing Address - Country:US
Mailing Address - Phone:440-731-0492
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-204-4315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1800933-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical