Basic Information
| Provider Information | |||||||||
| NPI: | 1427336403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATRAK | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | CAROLINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 456 LANCERS DR | ||||||||
| Address2: | |||||||||
| City: | WINTER SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327083306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078606540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2011 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 003945800 | 05 | FL | MEDICAID |