Healthcare Provider Details

I. General information

NPI: 1700791704
Provider Name (Legal Business Name): MATTIE LORRAINE CETIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MOONLIGHT DR
BARRE VT
05641-5122
US

IV. Provider business mailing address

26 MOONLIGHT DR
BARRE VT
05641-5122
US

V. Phone/Fax

Practice location:
  • Phone: 802-522-4391
  • Fax:
Mailing address:
  • Phone: 802-522-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: