Healthcare Provider Details

I. General information

NPI: 1154546513
Provider Name (Legal Business Name): MARY A MATTOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 OLIVE AVE MOHAVE VALLEY ELEM. SD16
MOHAVE VALLEY AZ
86440-9214
US

IV. Provider business mailing address

PO BOX 6221
MOHAVE VALLEY AZ
86446-6221
US

V. Phone/Fax

Practice location:
  • Phone: 928-768-2507
  • Fax:
Mailing address:
  • Phone: 928-768-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: