MEDICARE: MARCIE L MATA, LPC, LLC

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	101YP2500X	Professional Counselor	4971	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952752131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARCIE L MATA, LPC, LLC

Provider Business Mailing Address
First Line	:	109 CORONADO CT BLDG 7
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4929
Country	:	US
Telephone Number	:	970-308-4474
Fax Number	:	970-377-6767

Provider Business Practice Location Address
First Line	:	109 CORONADO CT BLDG 7
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4929
Country	:	US
Telephone Number	:	970-308-4474
Fax Number	:	970-377-6767

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	MARCIE LYNN MATA
Credential	:
Telephone Number	:	970-308-4474

Provider Enumeration Date	:	06/28/2016
Last Update Date	:	06/28/2016

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