Healthcare Provider Details

I. General information

NPI: 1285355099
Provider Name (Legal Business Name): ALEXIS MATTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 N NINA CIR UNIT 4
WASILLA AK
99654-5658
US

IV. Provider business mailing address

1770 N NINA CIR UNIT 4
WASILLA AK
99654-5658
US

V. Phone/Fax

Practice location:
  • Phone: 907-355-5302
  • Fax:
Mailing address:
  • Phone: 907-355-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier603612779
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerPREMERA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: