Provider Demographics
NPI:1851092712
Name:MATTSON, SUSAN (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 N LAST CHANCE GULCH APT 4A
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4107
Mailing Address - Country:US
Mailing Address - Phone:406-422-6645
Mailing Address - Fax:
Practice Address - Street 1:21 N LAST CHANCE GULCH APT 4A
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4107
Practice Address - Country:US
Practice Address - Phone:406-422-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty