Provider Demographics
NPI:1326127721
Name:MATTSON, RONDI (PHD)
Entity Type:Individual
Prefix:
First Name:RONDI
Middle Name:
Last Name:MATTSON
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 1:1785 EAST 1450 SOUTH
Mailing Address - Street 2:SUITE 237
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2464
Mailing Address - Country:US
Mailing Address - Phone:801-525-1131
Mailing Address - Fax:801-525-1181
Practice Address - Street 1:1785 EAST 1450 SOUTH
Practice Address - Street 2:SUITE 237
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-2464
Practice Address - Country:US
Practice Address - Phone:801-525-1131
Practice Address - Fax:801-525-1181
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6458327-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000079230Medicare PIN
NV2616204Medicaid
NV33109Medicare ID - Type Unspecified