Provider Demographics
NPI:1619065026
Name:DEMATATIS, ANNA PRISCILLA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:PRISCILLA
Last Name:DEMATATIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4572 S HAGADORN RD STE 2E
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:512-619-7748
Practice Address - Fax:517-349-3755
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013211103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical