Provider Demographics
NPI:1295071371
Name:MATTSON, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MATTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28362 FORESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39111 6 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3926
Practice Address - Country:US
Practice Address - Phone:586-940-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802069955104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker