Provider Demographics
NPI:1487287348
Name:MATTA, YANIALIZ (MSW)
Entity type:Individual
Prefix:MISS
First Name:YANIALIZ
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/ 15 BLOQ P# 828 URB. ALTURAS DE RIO GRANDE
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:787-226-4667
Mailing Address - Fax:
Practice Address - Street 1:C/ 15 BLOQ P# 828 URB. ALTURAS DE RIO GRANDE
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-226-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR134471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR134471717Medicaid