Provider Demographics
NPI:1184777872
Name:MATZEDER, MARY E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:MATZEDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8303 TOMASHAW ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-1571
Mailing Address - Country:US
Mailing Address - Phone:913-972-5179
Mailing Address - Fax:
Practice Address - Street 1:20705 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7222
Practice Address - Country:US
Practice Address - Phone:913-972-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0380103T00000X
KS882103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200441610AMedicaid
KS200441610AMedicaid
MOMA3502Medicare PIN
KSKA1624Medicare PIN