Provider Demographics
NPI:1841489754
Name:MATTISON, KATHRYN CHURCHILL (LICSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CHURCHILL
Last Name:MATTISON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAIN STREET
Mailing Address - Street 2:CAYA LLC SUITE 2D
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-466-5777
Mailing Address - Fax:978-466-5887
Practice Address - Street 1:20 MAIN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5530
Practice Address - Country:US
Practice Address - Phone:978-466-5777
Practice Address - Fax:978-466-5887
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10327481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical