Provider Demographics
NPI:1255978961
Name:MATTIX, KENDALL LEEANNE
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:LEEANNE
Last Name:MATTIX
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 1:41467 COUR BEAUNE
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591
Mailing Address - Country:US
Mailing Address - Phone:951-719-0790
Mailing Address - Fax:
Practice Address - Street 1:41689 ENTERPRISE CIR N STE 120
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5630
Practice Address - Country:US
Practice Address - Phone:951-587-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician