Healthcare Provider Details

I. General information

NPI: 1336711068
Provider Name (Legal Business Name): CASSANDRA MATEJKA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 13TH AVE E
WEST FARGO ND
58078-3468
US

IV. Provider business mailing address

1401 13TH AVE E
WEST FARGO ND
58078-3468
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-0060
  • Fax: 701-364-0065
Mailing address:
  • Phone: 701-364-0060
  • Fax: 701-364-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number649
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: