Provider Demographics
NPI:1861739948
Name:MATUTE-REYES, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MATUTE-REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10964 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7802
Mailing Address - Country:US
Mailing Address - Phone:914-494-8394
Mailing Address - Fax:
Practice Address - Street 1:10964 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-7802
Practice Address - Country:US
Practice Address - Phone:914-494-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106706100Medicaid