Provider Demographics
NPI:1972937704
Name:MATERA, MICHELE LYNN (ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:LYNN
Last Name:MATERA
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 E LAKELAND ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2028
Mailing Address - Country:US
Mailing Address - Phone:631-601-4113
Mailing Address - Fax:
Practice Address - Street 1:84 E LAKELAND ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2028
Practice Address - Country:US
Practice Address - Phone:631-601-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00213912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS