Provider Demographics
NPI:1285158337
Name:MATISAK, HEATHER L (PTA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:MATISAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:PA
Mailing Address - Zip Code:18224-2021
Mailing Address - Country:US
Mailing Address - Phone:570-766-2414
Mailing Address - Fax:
Practice Address - Street 1:1000 STACIE DR
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5690
Practice Address - Country:US
Practice Address - Phone:570-453-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI001862225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant