Provider Demographics
NPI:1487218111
Name:MATEJCZYK, SUSAN LOUISE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LOUISE
Last Name:MATEJCZYK
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 1:4265 DEER RUN CT
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2466
Mailing Address - Country:US
Mailing Address - Phone:219-916-8385
Mailing Address - Fax:
Practice Address - Street 1:1120 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3286
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:219-983-9681
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist