Healthcare Provider Details

I. General information

NPI: 1558589234
Provider Name (Legal Business Name): SANDRA LEE MATTSON EBELTOFT ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12606 E. MAIN ST.
MAYER AZ
86333
US

IV. Provider business mailing address

1950 LAZY MEADOW LN
PRESCOTT AZ
86303-5044
US

V. Phone/Fax

Practice location:
  • Phone: 928-642-1010
  • Fax: 928-632-4005
Mailing address:
  • Phone: 928-445-0121
  • Fax: 928-541-9043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: