Provider Demographics
NPI:1083804363
Name:MATTOX, ERICA MONIQUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:MONIQUE
Last Name:MATTOX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 BENTLEY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5677
Mailing Address - Country:US
Mailing Address - Phone:678-640-9045
Mailing Address - Fax:770-484-8534
Practice Address - Street 1:1450 BENTLEY RIDGE CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5677
Practice Address - Country:US
Practice Address - Phone:678-640-9045
Practice Address - Fax:770-484-8534
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist