Provider Demographics
NPI:1316490139
Name:MATTOS, SANDRA AISSA (SLP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:AISSA
Last Name:MATTOS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 CALLE WILLIAM JONES
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00915-3418
Mailing Address - Country:US
Mailing Address - Phone:787-512-0142
Mailing Address - Fax:
Practice Address - Street 1:202 B SANTA ROSA MALL OFIC.
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00915-3418
Practice Address - Country:US
Practice Address - Phone:787-780-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0003235Z00000X
PR3235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR59573OtherPROFFICE OF REGULATION AND CERTIFICATION OF HELTH PROFFESIONALS
PR0003OtherSPEECH-LANGUAGE PATHOLOGIST LICENCE (ORCHP)