Provider Demographics
NPI:1336568740
Name:MATLOCK, MARCIE (LMT)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 ARENDELL PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-8711
Mailing Address - Country:US
Mailing Address - Phone:614-300-7917
Mailing Address - Fax:
Practice Address - Street 1:4530 ARENDELL PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-8711
Practice Address - Country:US
Practice Address - Phone:614-300-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.020950174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist