Provider Demographics
NPI:1275710774
Name:MATTESON COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:MATTESON COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATTESON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:856-223-1571
Mailing Address - Street 1:4 GAZELL LN
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-4752
Mailing Address - Country:US
Mailing Address - Phone:856-223-1571
Mailing Address - Fax:856-223-1510
Practice Address - Street 1:4 GAZELL LN
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-4752
Practice Address - Country:US
Practice Address - Phone:856-223-1571
Practice Address - Fax:856-223-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05248200251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0162213Medicaid