Healthcare Provider Details

I. General information

NPI: 1699516336
Provider Name (Legal Business Name): CHRISTENA MATZEDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 GOBLIN DR
HARRISON AR
72601-8885
US

IV. Provider business mailing address

5148 W STONE MNR
ROGERS AR
72758-8210
US

V. Phone/Fax

Practice location:
  • Phone: 870-654-3869
  • Fax:
Mailing address:
  • Phone: 870-350-0744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number202730
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: