Provider Demographics
NPI:1427663319
Name:MATTHEWS, LARINA DEIRELAND
Entity type:Individual
Prefix:
First Name:LARINA
Middle Name:DEIRELAND
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6375 CAPITOL KNL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4430
Mailing Address - Country:US
Mailing Address - Phone:414-803-7188
Mailing Address - Fax:
Practice Address - Street 1:6375 CAPITOL KNL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4430
Practice Address - Country:US
Practice Address - Phone:414-803-7188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist