Basic Information
| Provider Information | |||||||||
| NPI: | 1275622672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLOS | ||||||||
| FirstName: | NORBERTO | ||||||||
| MiddleName: | MATA | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 N DATE ST | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607376960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41715 WINCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925904808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517191414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS24788 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | FB076Z | 01 | CA | MEDICARE PTAN | OTHER | W14158 | 01 | CA | FACILITY PTAN | OTHER | ZZZ20041Z | 01 | CA | FACILITY PTAN | OTHER |