Provider Demographics
NPI:1134503949
Name:MATTIE, COLLEEN M
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:MATTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E TERRA LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2725
Mailing Address - Country:US
Mailing Address - Phone:636-240-2072
Mailing Address - Fax:
Practice Address - Street 1:555 E TERRA LN
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2725
Practice Address - Country:US
Practice Address - Phone:636-240-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODESE LIFETIME235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist