Provider Demographics
NPI:1376889642
Name:MATLOCK, MICHELLE RENEE (MT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CORUNNA AVE
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-3504
Mailing Address - Country:US
Mailing Address - Phone:989-277-4047
Mailing Address - Fax:
Practice Address - Street 1:206 CORUNNA AVE
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-3504
Practice Address - Country:US
Practice Address - Phone:989-277-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist