Provider Demographics
NPI:1760946123
Name:MATZEN, LAUREN DEBRA (MAC,LICAC,NCCAOM DIP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:DEBRA
Last Name:MATZEN
Suffix:
Gender:F
Credentials:MAC,LICAC,NCCAOM DIP
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:DEBRA
Other - Last Name:MATZEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:52 JAGGER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4822
Mailing Address - Country:US
Mailing Address - Phone:516-527-6698
Mailing Address - Fax:
Practice Address - Street 1:52 JAGGER LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4822
Practice Address - Country:US
Practice Address - Phone:516-527-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000656171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist