Provider Demographics
NPI:1497093579
Name:MATTESON, ANDRAYA M (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:ANDRAYA
Middle Name:M
Last Name:MATTESON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 W 4TH AVE
Mailing Address - Street 2:P204
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8596
Mailing Address - Country:US
Mailing Address - Phone:575-640-2210
Mailing Address - Fax:
Practice Address - Street 1:1215 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5472
Practice Address - Country:US
Practice Address - Phone:509-543-6703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60181127224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant