Provider Demographics
NPI:1629407689
Name:MATTSON, MARY LOU (LCSW, DBTC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:MATTSON
Suffix:
Gender:F
Credentials:LCSW, DBTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 CITY WALK DR UNIT 431
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6953
Mailing Address - Country:US
Mailing Address - Phone:920-312-1477
Mailing Address - Fax:
Practice Address - Street 1:10300 CITY WALK DR UNIT 431
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-6953
Practice Address - Country:US
Practice Address - Phone:920-312-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-10
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7778-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical