Healthcare Provider Details

I. General information

NPI: 1750427464
Provider Name (Legal Business Name): MARCY MATASICK M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-5146
US

IV. Provider business mailing address

PO BOX 1134
SANDIA PARK NM
87047-1134
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-1228
  • Fax: 505-286-1228
Mailing address:
  • Phone: 505-286-1228
  • Fax: 505-286-1228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3410
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: