Provider Demographics
NPI:1659932101
Name:MATAESE, ETELINI MEVINA
Entity Type:Individual
Prefix:
First Name:ETELINI
Middle Name:MEVINA
Last Name:MATAESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ETELINI
Other - Middle Name:MEVINA
Other - Last Name:SIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3600 E 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3416
Mailing Address - Country:US
Mailing Address - Phone:907-743-8733
Mailing Address - Fax:
Practice Address - Street 1:1700 A ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-5139
Practice Address - Country:US
Practice Address - Phone:907-743-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician