Provider Demographics
NPI:1790262202
Name:MATTUS, OLIVIA (CPC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MATTUS
Suffix:
Gender:F
Credentials:CPC
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:RIVAS DEL RIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:748 14TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-200-5419
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA60871230175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104938Medicaid