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General NPI Number Information
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NPI Number | 1649664897
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Entity Type | Organization
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Legal Business Name | MATTIES RANCH LLC
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Dates
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Enumeration Date | 03/25/2015
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Last Update Date | 10/05/2015
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Provider Practice Location Address
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Address Line | 5014 OAK BEND CIRCLE
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City | DENTON
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State | TX
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Zip | 76208
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Country | US
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Telephone | 940-383-0870
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Fax |
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Provider Business Mailing Address
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Address Line | 12217 LANGLEY HILL DR
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City | KELLER
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State | TX
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Zip | 76244
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Country | US
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Telephone | 817-586-8527
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MARC A. VALENTI
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Credential |
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Telephone | 817-586-8527
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 21805
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License Number State | TX
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