Provider Demographics
NPI:1982147153
Name:MATTESON, JULIANNE (PT)
Entity Type:Individual
Prefix:DR
First Name:JULIANNE
Middle Name:
Last Name:MATTESON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12579 N AVONDALE LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7529
Mailing Address - Country:US
Mailing Address - Phone:270-853-2570
Mailing Address - Fax:208-762-0252
Practice Address - Street 1:8944 N HESS ST STE B
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9183
Practice Address - Country:US
Practice Address - Phone:208-762-0251
Practice Address - Fax:208-762-0252
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006972225100000X
IDPT5334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist