Provider Demographics
NPI:1578073623
Name:MATTA, MARY ANNE (LAC)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 MILITIA HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-1913
Mailing Address - Country:US
Mailing Address - Phone:267-314-7555
Mailing Address - Fax:
Practice Address - Street 1:447 MILITIA HILL RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-1913
Practice Address - Country:US
Practice Address - Phone:267-314-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001239171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty