1093368359 NPI number — SAMANTHA LESLIE MATESIC LMHC

Table of content: SAMANTHA LESLIE MATESIC LMHC (NPI 1093368359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093368359 NPI number — SAMANTHA LESLIE MATESIC LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATESIC
Provider First Name:
SAMANTHA
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093368359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 S FEDERAL HWY APT 253
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33435-2936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-921-7803
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 N UNIVERSITY DR STE 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33065-5083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-571-1557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1055493-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105549300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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