Provider Demographics
NPI:1740886639
Name:WEBER, MATTIE (LMT)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12497 CASTLE COURT DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-4273
Mailing Address - Country:US
Mailing Address - Phone:619-813-8011
Mailing Address - Fax:
Practice Address - Street 1:9930 MAINE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3108
Practice Address - Country:US
Practice Address - Phone:619-813-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14105225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist