Provider Demographics
NPI:1366632747
Name:MATTOON, LYSSABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYSSABETH
Middle Name:
Last Name:MATTOON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:BETH
Other - Last Name:MATTOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:414 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-3718
Mailing Address - Country:US
Mailing Address - Phone:209-720-2960
Mailing Address - Fax:
Practice Address - Street 1:414 W 21ST ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3718
Practice Address - Country:US
Practice Address - Phone:209-720-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8180OtherMEDI-CAL