Provider Demographics
NPI:1790142909
Name:MATTISON, ERNEST FREDRICK (LPC-I)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:FREDRICK
Last Name:MATTISON
Suffix:
Gender:M
Credentials:LPC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3411
Mailing Address - Country:US
Mailing Address - Phone:803-474-5129
Mailing Address - Fax:
Practice Address - Street 1:1011 EAST AVE
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3411
Practice Address - Country:US
Practice Address - Phone:803-474-5129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7053Medicaid