Provider Demographics
NPI:1285665075
Name:MATTIE, MICHELE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:MATTIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 PIERCE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5731
Mailing Address - Country:US
Mailing Address - Phone:570-718-1150
Mailing Address - Fax:570-714-1321
Practice Address - Street 1:517 PIERCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5731
Practice Address - Country:US
Practice Address - Phone:570-718-1150
Practice Address - Fax:570-714-1321
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008609L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2057094OtherCIGNA
PA359151OtherBC/BS