Provider Demographics
NPI:1962560995
Name:MATYJA, COURTNEY LAINE (AUD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:LAINE
Last Name:MATYJA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:L
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2515 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6135
Mailing Address - Country:US
Mailing Address - Phone:501-205-1215
Mailing Address - Fax:
Practice Address - Street 1:2515 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-205-1215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1918231H00000X
AR284231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y675Medicare UPIN