Provider Demographics
NPI:1598209363
Name:MATTIS, KATHERINE (RD, CDN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:MATTIS
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1326
Mailing Address - Country:US
Mailing Address - Phone:203-732-7585
Mailing Address - Fax:203-732-7579
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered