Provider Demographics
NPI:1992389175
Name:MATILTON, SERENA
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:MATILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 O ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-5789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 O ST
Practice Address - Street 2:SUITE C
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-5789
Practice Address - Country:US
Practice Address - Phone:303-989-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician