Provider Demographics
NPI:1598863680
Name:MATTISON, ROGER W (MS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:MATTISON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 JANES RD
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4744
Mailing Address - Country:US
Mailing Address - Phone:707-822-9122
Mailing Address - Fax:707-822-1969
Practice Address - Street 1:3770 JANES RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4744
Practice Address - Country:US
Practice Address - Phone:707-822-9122
Practice Address - Fax:707-822-1969
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 301231H00000X
CAHA 954237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter