Provider Demographics
NPI:1275358111
Name:MATTHES, MARILYN (LAC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:MATTHES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HOLDER PL APT 2F
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5216
Mailing Address - Country:US
Mailing Address - Phone:917-923-3008
Mailing Address - Fax:
Practice Address - Street 1:10 HOLDER PL APT 2F
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5216
Practice Address - Country:US
Practice Address - Phone:917-923-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-16
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4235171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist