Provider Demographics
NPI:1912034760
Name:MATTISEN, ANDREA (LICSW BCD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MATTISEN
Suffix:
Gender:F
Credentials:LICSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1332
Mailing Address - Country:US
Mailing Address - Phone:617-742-2270
Mailing Address - Fax:617-742-2270
Practice Address - Street 1:162 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-1332
Practice Address - Country:US
Practice Address - Phone:617-742-2270
Practice Address - Fax:617-742-2270
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1017001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA101700OtherLICENSE