Provider Demographics
NPI:1629498183
Name:MATTSON, BLAIR WILLIAM (LMT)
Entity Type:Individual
Prefix:MR
First Name:BLAIR
Middle Name:WILLIAM
Last Name:MATTSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1043
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-1031
Mailing Address - Country:US
Mailing Address - Phone:208-881-4540
Mailing Address - Fax:
Practice Address - Street 1:45 E LITTLE AVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5138
Practice Address - Country:US
Practice Address - Phone:208-354-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS909225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist