Provider Demographics
NPI:1720670789
Name:MATTIOLI, JOHNNIE FERDINAND (AMFT)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:FERDINAND
Last Name:MATTIOLI
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12983 MORENO BEACH DR APT 13208
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4437
Mailing Address - Country:US
Mailing Address - Phone:619-822-6906
Mailing Address - Fax:
Practice Address - Street 1:29019 CARILLO CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-6501
Practice Address - Country:US
Practice Address - Phone:951-488-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist