Provider Demographics
NPI:1093123036
Name:VAIL, MATTIE (LPN)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:VAIL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 ROSELAWN AVE NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-5326
Mailing Address - Country:US
Mailing Address - Phone:330-219-2374
Mailing Address - Fax:
Practice Address - Street 1:629 ROSELAWN AVE NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5326
Practice Address - Country:US
Practice Address - Phone:330-219-2374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN116132103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst