Provider Demographics
NPI:1821325481
Name:MATTISON, HEATHER A (RPT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:A
Last Name:MATTISON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4553
Mailing Address - Country:US
Mailing Address - Phone:860-875-0771
Mailing Address - Fax:860-872-2941
Practice Address - Street 1:22 SOUTH ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4553
Practice Address - Country:US
Practice Address - Phone:860-875-0771
Practice Address - Fax:860-872-2941
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0004786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist