Provider Demographics
NPI:1790040004
Name:MATTIS, KATHLEEN G (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:G
Last Name:MATTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 WILLIAM MANOR DR
Mailing Address - Street 2:
Mailing Address - City:WADDINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:13694-3186
Mailing Address - Country:US
Mailing Address - Phone:315-388-3074
Mailing Address - Fax:
Practice Address - Street 1:29 WILLIAM MANOR DR
Practice Address - Street 2:
Practice Address - City:WADDINGTON
Practice Address - State:NY
Practice Address - Zip Code:13694-3186
Practice Address - Country:US
Practice Address - Phone:315-388-3074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0772931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical