Provider Demographics
NPI:1609124320
Name:MATANZO, TATIANA M I
Entity type:Individual
Prefix:MRS
First Name:TATIANA
Middle Name:M
Last Name:MATANZO
Suffix:I
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 1:14901 E HAMPDEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-5037
Mailing Address - Country:US
Mailing Address - Phone:720-260-4115
Mailing Address - Fax:720-836-6394
Practice Address - Street 1:14901 E HAMPDEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5037
Practice Address - Country:US
Practice Address - Phone:720-260-4115
Practice Address - Fax:720-836-6394
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COLPC.0021017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program