Provider Demographics
NPI:1386358653
Name:MATA, JOSE MANUEL III (MA, LMFT-A)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MANUEL
Last Name:MATA
Suffix:III
Gender:M
Credentials:MA, LMFT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 S W S YOUNG DR STE 116A
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5314
Mailing Address - Country:US
Mailing Address - Phone:254-213-3705
Mailing Address - Fax:
Practice Address - Street 1:2201 S W S YOUNG DR STE 116A
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5314
Practice Address - Country:US
Practice Address - Phone:254-213-3705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204741106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist