Provider Demographics
NPI:1538632062
Name:MATULKA, LISA (MA83905)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MATULKA
Suffix:
Gender:F
Credentials:MA83905
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 JONATHANS BAY CIR APT 301
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7255
Mailing Address - Country:US
Mailing Address - Phone:704-860-4959
Mailing Address - Fax:
Practice Address - Street 1:3411 BONITA BEACH RD STE 305
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4155
Practice Address - Country:US
Practice Address - Phone:239-529-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA83905225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty