MEDICARE: MARISSA MATZENAUER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	96159	TX
2	101YM0800X	Mental Health Counselor	96159	TX

General Provider Information

NPI Number	:	1942143706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA MATZENAUER

Provider Business Mailing Address
First Line	:	4635 NE STALLINGS DR STE 104
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1667
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 NE STALLINGS DR STE 104
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1667
Country	:	US
Telephone Number	:	936-228-6670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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Directions to “ MARISSA MATZENAUER ” Practice Location

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