Provider Demographics
NPI:1740945773
Name:MATESICH, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MATESICH
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 1:1000 JEFFERSON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 CHESTNUT ST STE 1520
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4315
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional