Provider Demographics
NPI:1104010883
Name:MATZ, MARY KATHRYN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:MATZ
Suffix:
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 1:446 CENTER ST
Mailing Address - Street 2:PO BOX 396
Mailing Address - City:TAYLORS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55084-1118
Mailing Address - Country:US
Mailing Address - Phone:651-329-1612
Mailing Address - Fax:
Practice Address - Street 1:446 CENTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORS FALLS
Practice Address - State:MN
Practice Address - Zip Code:55084-1118
Practice Address - Country:US
Practice Address - Phone:651-329-1612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1046986-1-AFC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator