Provider Demographics
NPI:1821234683
Name:MATTSON, ALICIA A (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:A
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BRIARPATCH LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON CORNERS
Mailing Address - State:NY
Mailing Address - Zip Code:12514-3030
Mailing Address - Country:US
Mailing Address - Phone:914-456-9702
Mailing Address - Fax:
Practice Address - Street 1:24 BRIARPATCH LN
Practice Address - Street 2:
Practice Address - City:CLINTON CORNERS
Practice Address - State:NY
Practice Address - Zip Code:12514-3030
Practice Address - Country:US
Practice Address - Phone:914-456-9702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007197171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor