Provider Demographics
NPI:1740378959
Name:MATESICH, CHARLENE ANNE (MS CCCA REEGEPNCST)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:ANNE
Last Name:MATESICH
Suffix:
Gender:F
Credentials:MS CCCA REEGEPNCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 E 41ST AVE
Mailing Address - Street 2:APT A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5413
Mailing Address - Country:US
Mailing Address - Phone:907-561-0959
Mailing Address - Fax:
Practice Address - Street 1:2530 DEBARR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:800-478-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK43231H00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic