Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | NJDCATEMP | NJ |
NPI | 1366062101 |
---|---|
Provider Name | Miguel Mateo |
First Address | Woodbridge, NJ 07095-3800 |
Second Address | Newark, NJ 07114-1349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2020 |
Last Update Date | 22/04/2020 |