Provider Demographics
NPI:1477805687
Name:MATTESON, MARTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MATTESON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 W PARK
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4013
Mailing Address - Country:US
Mailing Address - Phone:830-456-4781
Mailing Address - Fax:
Practice Address - Street 1:203 W PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4013
Practice Address - Country:US
Practice Address - Phone:830-456-4781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical