Provider Demographics
NPI:1639322647
Name:MATZELLE, GREGORY ALAN (MA, LMSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:MATZELLE
Suffix:
Gender:M
Credentials:MA, LMSW
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 1056
Mailing Address - Street 2:8455 RATTALEE LK RD
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48347-1056
Mailing Address - Country:US
Mailing Address - Phone:248-935-0092
Mailing Address - Fax:
Practice Address - Street 1:10785 S. SAGINAW ST.
Practice Address - Street 2:SUITE A, BUILDING E
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-695-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010151881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical