Provider Demographics
NPI:1477200392
Name:MATTISON, THERESA (MS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MATTISON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 ESPLANADE WAY APT 12213
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-3758
Mailing Address - Country:US
Mailing Address - Phone:716-867-4689
Mailing Address - Fax:
Practice Address - Street 1:1801 MICCOSUKEE CMNS # D
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5433
Practice Address - Country:US
Practice Address - Phone:850-488-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator