Provider Demographics
NPI:1629562707
Name:MATLOCK-SHALLY, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:MATLOCK-SHALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:SHALLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LOM
Mailing Address - Street 1:437 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-1717
Mailing Address - Country:US
Mailing Address - Phone:267-241-4321
Mailing Address - Fax:
Practice Address - Street 1:437 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-1717
Practice Address - Country:US
Practice Address - Phone:267-241-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000221171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist