Provider Demographics
NPI:1689117194
Name:DEPOE, MATEA MICHELLE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MATEA
Middle Name:MICHELLE
Last Name:DEPOE
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GREAT NORTHERN AVE
Mailing Address - Street 2:APT B16
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1605
Mailing Address - Country:US
Mailing Address - Phone:406-207-9149
Mailing Address - Fax:
Practice Address - Street 1:2360 MULLAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-542-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTATR-LAT-LIC-14702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer