Provider Demographics
NPI:1144564402
Name:MATTOX-LARSON, PATRICIA JOAN (MS CCC-SP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JOAN
Last Name:MATTOX-LARSON
Suffix:
Gender:F
Credentials:MS CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 WHITE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-5154
Mailing Address - Country:US
Mailing Address - Phone:603-356-7294
Mailing Address - Fax:
Practice Address - Street 1:1251 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5154
Practice Address - Country:US
Practice Address - Phone:603-356-7294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0320235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist