Provider Demographics
NPI:1316174311
Name:MATZ, LORA ELINORE (MS,LICSW)
Entity type:Individual
Prefix:MS
First Name:LORA
Middle Name:ELINORE
Last Name:MATZ
Suffix:
Gender:F
Credentials:MS,LICSW
Other - Prefix:MS
Other - First Name:DOLORES
Other - Middle Name:E
Other - Last Name:DEVORE-MATZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LICSW
Mailing Address - Street 1:7616 CURRELL BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2290
Mailing Address - Country:US
Mailing Address - Phone:651-259-9763
Mailing Address - Fax:
Practice Address - Street 1:7616 CURRELL BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2290
Practice Address - Country:US
Practice Address - Phone:651-259-9763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical