Provider Demographics
NPI:1417039918
Name:MATTOCKS, SUSAN OLETA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:OLETA
Last Name:MATTOCKS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 WILSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5094
Mailing Address - Country:US
Mailing Address - Phone:406-233-4219
Mailing Address - Fax:406-233-2503
Practice Address - Street 1:2600 WILSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5094
Practice Address - Country:US
Practice Address - Phone:406-233-4219
Practice Address - Fax:406-233-2503
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical