Provider Demographics
NPI:1831158732
Name:MATTSON, AUDREY J (PHD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:J
Last Name:MATTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59756-0223
Mailing Address - Country:US
Mailing Address - Phone:406-693-2103
Mailing Address - Fax:
Practice Address - Street 1:800 W PLATINUM ST
Practice Address - Street 2:SUITE F
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2200
Practice Address - Country:US
Practice Address - Phone:406-693-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001634103T00000X
MT375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS77972Medicare UPIN