Provider Demographics
NPI:1689914566
Name:MATTIS, MICHELE LEE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:MATTIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 OLD WILLIAM PENN HWY
Mailing Address - Street 2:STE B
Mailing Address - City:MURRYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15668-1930
Mailing Address - Country:US
Mailing Address - Phone:724-593-7509
Mailing Address - Fax:
Practice Address - Street 1:4520 OLD WILLIAM PENN HWY
Practice Address - Street 2:STE B
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15668-1930
Practice Address - Country:US
Practice Address - Phone:724-593-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017844103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist