Provider Demographics
NPI:1982908471
Name:MATTISE, CHRISTINA MARIE (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:CHRISTINA
Middle Name:MARIE
Last Name:MATTISE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2097 SE FERN PARK DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-8005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PALM BEACH RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4044
Practice Address - Country:US
Practice Address - Phone:772-288-1860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10807225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist