Provider Demographics
NPI:1518024330
Name:MATTIS, ELEANOR IHMSEN (MSW)
Entity Type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:IHMSEN
Last Name:MATTIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6073 ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-2721
Mailing Address - Country:US
Mailing Address - Phone:703-550-4334
Mailing Address - Fax:
Practice Address - Street 1:6073 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2721
Practice Address - Country:US
Practice Address - Phone:703-550-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040023121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF553-001OtherBLUE CROSS
VAF553-001OtherBLUE CROSS