Provider Demographics
NPI:1508622556
Name:MATIENZO, IRISH
Entity Type:Individual
Prefix:
First Name:IRISH
Middle Name:
Last Name:MATIENZO
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 1:969 GLAZEBROOK LOOP
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-6610
Mailing Address - Country:US
Mailing Address - Phone:419-944-3670
Mailing Address - Fax:
Practice Address - Street 1:969 GLAZEBROOK LOOP
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-6610
Practice Address - Country:US
Practice Address - Phone:419-944-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist