Provider Demographics
NPI:1215104211
Name:MATZ, DELORES GENEVIEVE (LCMT)
Entity type:Individual
Prefix:
First Name:DELORES
Middle Name:GENEVIEVE
Last Name:MATZ
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 5TH ST NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1917
Mailing Address - Country:US
Mailing Address - Phone:763-300-1022
Mailing Address - Fax:763-633-7827
Practice Address - Street 1:200 5TH ST NW
Practice Address - Street 2:SUITE D
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1917
Practice Address - Country:US
Practice Address - Phone:763-300-1022
Practice Address - Fax:763-633-7827
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMT 08 - 50171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor