Provider Demographics
NPI:1619397569
Name:MATTSON, HUSTON JOHNSON IV (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:HUSTON
Middle Name:JOHNSON
Last Name:MATTSON
Suffix:IV
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5206 CHELSEY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8618
Mailing Address - Country:US
Mailing Address - Phone:412-979-9047
Mailing Address - Fax:
Practice Address - Street 1:4901 WEDDINGTON RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-6267
Practice Address - Country:US
Practice Address - Phone:704-296-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0046792255A2300X
NCLAT-24742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer