Provider Demographics
NPI:1821145053
Name:MATTIS, SARA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:G
Last Name:MATTIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-2900
Mailing Address - Country:US
Mailing Address - Phone:781-729-5655
Mailing Address - Fax:
Practice Address - Street 1:573 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-2900
Practice Address - Country:US
Practice Address - Phone:781-729-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05734OtherBLUE CROSS PROVIDER ID