MEDICARE: DR. JOE ALLEN MATTOX PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	9427	CA

General Provider Information

NPI Number	:	1336295237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOE ALLEN MATTOX PH.D.

Provider Business Mailing Address
First Line	:	436 14TH ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94612-2703
Country	:	US
Telephone Number	:	510-315-2337
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 14TH ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94612-2703
Country	:	US
Telephone Number	:	510-315-2337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	02/11/2022

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