Provider Demographics
NPI:1417967415
Name:MATTSON, BRENDA (PT BOCO)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PT BOCO
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:MATTSON
Other - Last Name:HARFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT BOCO
Mailing Address - Street 1:19 PHILLIPS ROAD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105
Mailing Address - Country:US
Mailing Address - Phone:207-781-5369
Mailing Address - Fax:207-781-5862
Practice Address - Street 1:170 US ROUTE ONE
Practice Address - Street 2:SUITE 180
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105
Practice Address - Country:US
Practice Address - Phone:207-781-5369
Practice Address - Fax:207-781-5862
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC15212222Z00000X
MEPT0512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M23095OtherCIGNA
2434074OtherAETNA DME
M230950OtherCIGNA DME
1042321OtherAETNA
018251OtherANTHEM BCBS
37938OtherHARVARD PILGRIM