Provider Demographics
NPI:1952752131
Name:MARCIE L MATA, LPC, LLC
Entity Type:Organization
Organization Name:MARCIE L MATA, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-308-4474
Mailing Address - Street 1:109 CORONADO CT BLDG 7
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4929
Mailing Address - Country:US
Mailing Address - Phone:970-308-4474
Mailing Address - Fax:970-377-6767
Practice Address - Street 1:109 CORONADO CT BLDG 7
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4929
Practice Address - Country:US
Practice Address - Phone:970-308-4474
Practice Address - Fax:970-377-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4971101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24785229Medicaid