Provider Demographics
NPI:1073552790
Name:MATTIA, SANDRA D (LMSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:MATTIA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 SYLVANWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3126
Mailing Address - Country:US
Mailing Address - Phone:248-828-4306
Mailing Address - Fax:
Practice Address - Street 1:30701 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0987
Practice Address - Country:US
Practice Address - Phone:248-288-9333
Practice Address - Fax:248-288-1362
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801066583101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN47440006Medicare ID - Type Unspecified