Healthcare Provider Details

I. General information

NPI: 1487394870
Provider Name (Legal Business Name): MACIE MATTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 BEACON HILL RD
COLUMBUS OH
43228-4442
US

IV. Provider business mailing address

5131 BEACON HILL RD STE 120
COLUMBUS OH
43228-4442
US

V. Phone/Fax

Practice location:
  • Phone: 614-544-1994
  • Fax:
Mailing address:
  • Phone: 614-544-1994
  • Fax: 614-544-0052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: