Provider Demographics
NPI:1851665145
Name:MATTSON, BRENDAN ERIK (LAC)
Entity Type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:ERIK
Last Name:MATTSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 N ASHLAND AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1202
Mailing Address - Country:US
Mailing Address - Phone:773-301-1398
Mailing Address - Fax:773-477-4109
Practice Address - Street 1:4214 N ASHLAND AVE # 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1202
Practice Address - Country:US
Practice Address - Phone:773-301-1398
Practice Address - Fax:773-477-4109
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-03
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001059171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist