Provider Demographics
NPI:1598842163
Name:MATTIS, LAURA LYNN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:MATTIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 S ALMA SCHOOL RD APT 2085
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5565
Mailing Address - Country:US
Mailing Address - Phone:480-296-6818
Mailing Address - Fax:
Practice Address - Street 1:5440 E SOUTHERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2779
Practice Address - Country:US
Practice Address - Phone:480-641-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist