Basic Information
| Provider Information | |||||||||
| NPI: | 1780100503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDREW | ||||||||
| FirstName: | MATRONA | ||||||||
| MiddleName: | MARLENE | ||||||||
| NamePrefix: | PROF. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995760130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WALLACE STREET | ||||||||
| Address2: | |||||||||
| City: | NEW STUYAHOK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076933150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 08/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.