Provider Demographics
NPI:1396218962
Name:MATTOCKS, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MATTOCKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 TWIN BROOK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1692
Mailing Address - Country:US
Mailing Address - Phone:704-904-0319
Mailing Address - Fax:
Practice Address - Street 1:1401 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-6300
Practice Address - Country:US
Practice Address - Phone:704-461-3037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician