Provider Demographics
NPI:1194298711
Name:MATTERN, DANIEL WALTER (LMT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:WALTER
Last Name:MATTERN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39645 RAMBLER DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-5158
Mailing Address - Country:US
Mailing Address - Phone:586-822-5706
Mailing Address - Fax:
Practice Address - Street 1:39645 RAMBLER DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-5158
Practice Address - Country:US
Practice Address - Phone:586-822-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006690225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist