Provider Demographics
NPI:1619282936
Name:DIDION MATTICE, LEA MIEKO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:MIEKO
Last Name:DIDION MATTICE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:MIEKO
Other - Last Name:DIDION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:50 IRVING ST NW
Mailing Address - Street 2:116B
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20422-0001
Mailing Address - Country:US
Mailing Address - Phone:202-745-8000
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:116B
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4104103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical