Provider Demographics
NPI:1043336514
Name:MATTSON, ROBERT ERIC (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ERIC
Last Name:MATTSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:GWYNEDD
Mailing Address - State:PA
Mailing Address - Zip Code:19436-0258
Mailing Address - Country:US
Mailing Address - Phone:215-916-3458
Mailing Address - Fax:
Practice Address - Street 1:2990 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-1830
Practice Address - Country:US
Practice Address - Phone:215-916-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002998L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR06477Medicare UPIN
PA178075Medicare ID - Type Unspecified