Provider Demographics
NPI:1679747869
Name:MATTSON, EMILY HOLLY (LMP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:HOLLY
Last Name:MATTSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14968 EMERSON CT
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-7571
Mailing Address - Country:US
Mailing Address - Phone:503-969-6342
Mailing Address - Fax:
Practice Address - Street 1:210 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3369
Practice Address - Country:US
Practice Address - Phone:360-693-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist