Provider Demographics
NPI:1851857254
Name:MATEJKA, GWENDALYN NICOLE
Entity Type:Individual
Prefix:
First Name:GWENDALYN
Middle Name:NICOLE
Last Name:MATEJKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 BROWER CREST DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1745
Mailing Address - Country:US
Mailing Address - Phone:832-297-1941
Mailing Address - Fax:
Practice Address - Street 1:4903 BROWER CREST DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1745
Practice Address - Country:US
Practice Address - Phone:832-297-1941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer