Provider Demographics
NPI:1104717495
Name:VANMATRE, MACIE ANN
Entity type:Individual
Prefix:
First Name:MACIE
Middle Name:ANN
Last Name:VANMATRE
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 1:8090 W 5TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-7255
Mailing Address - Country:US
Mailing Address - Phone:208-457-2544
Mailing Address - Fax:
Practice Address - Street 1:8090 W 5TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-7255
Practice Address - Country:US
Practice Address - Phone:208-457-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID103K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program