Provider Demographics
NPI:1881919082
Name:MATTESON, DERRIC K (LMP)
Entity type:Individual
Prefix:MR
First Name:DERRIC
Middle Name:K
Last Name:MATTESON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8432 6TH AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1056
Mailing Address - Country:US
Mailing Address - Phone:253-579-8664
Mailing Address - Fax:
Practice Address - Street 1:8432 6TH AVE APT 4
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1056
Practice Address - Country:US
Practice Address - Phone:253-579-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60101907172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist