Basic Information
| Provider Information | |||||||||
| NPI: | 1841533213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMATTEO | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | TLLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MESSISCO | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | TLLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1821 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137732305 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1660 FORT ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343044159 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.