Provider Demographics
NPI:1477655314
Name:MICHELE MATTIE, PHD, LLC
Entity Type:Organization
Organization Name:MICHELE MATTIE, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:570-718-1150
Mailing Address - Street 1:517 PIERCE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5731
Mailing Address - Country:US
Mailing Address - Phone:570-718-1150
Mailing Address - Fax:570-714-1321
Practice Address - Street 1:517 PIERCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5731
Practice Address - Country:US
Practice Address - Phone:570-718-1150
Practice Address - Fax:570-714-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008609L103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1285665075OtherINDIVIDUAL NPI
PA359151OtherBLUE SHIELD