Provider Demographics
NPI:1952884496
Name:OVERTON, MATTIE JANE (DPT)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:JANE
Last Name:OVERTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 190
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3634
Mailing Address - Country:US
Mailing Address - Phone:949-340-6927
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 190
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3634
Practice Address - Country:US
Practice Address - Phone:949-340-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2952972081N0008X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation