1477655314 NPI number — MICHELE MATTIE, PHD, LLC

Table of content: (NPI 1477655314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477655314 NPI number — MICHELE MATTIE, PHD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELE MATTIE, PHD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1477655314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
517 PIERCE ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-5731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-718-1150
Provider Business Mailing Address Fax Number:
570-714-1321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 PIERCE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-5731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-718-1150
Provider Business Practice Location Address Fax Number:
570-714-1321
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATTIE
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-718-1150

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  PS008609L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1285665075 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 359151 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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