Provider Demographics
NPI:1073642450
Name:MATTSON, SANDRA LEAH (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEAH
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7555 N ORACLE RD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6330
Mailing Address - Country:US
Mailing Address - Phone:520-990-4931
Mailing Address - Fax:
Practice Address - Street 1:7555 N ORACLE RD UNIT 4
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85704-6330
Practice Address - Country:US
Practice Address - Phone:520-990-4931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ986103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ332312Medicaid
AZ0004655554Medicare UPIN
AZAZ0616660Medicare UPIN
AZ332312Medicaid