Provider Demographics
NPI:1396419446
Name:MATTSON, SHAWKAREE LENAE
Entity Type:Individual
Prefix:
First Name:SHAWKAREE
Middle Name:LENAE
Last Name:MATTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWKAREE
Other - Middle Name:LENAE
Other - Last Name:DOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:248 E ST NW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1660
Mailing Address - Country:US
Mailing Address - Phone:509-760-5378
Mailing Address - Fax:
Practice Address - Street 1:618 S ALDER ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1760
Practice Address - Country:US
Practice Address - Phone:509-764-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician