Provider Demographics
NPI:1083697304
Name:MATTESON, KRISTIN J (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:J
Last Name:MATTESON
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 1:740 OAK AVE
Mailing Address - Street 2:#B
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:760-729-6455
Mailing Address - Fax:760-729-6455
Practice Address - Street 1:740 OAK AVE
Practice Address - Street 2:#B
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:760-729-6455
Practice Address - Fax:760-729-6455
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA PSY 14416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14416AMedicare ID - Type Unspecified