Healthcare Provider Details

I. General information

NPI: 1083697304
Provider Name (Legal Business Name): KRISTIN J MATTESON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 OAK AVE #B
CARLSBAD CA
92008
US

IV. Provider business mailing address

740 OAK AVE #B
CARLSBAD CA
92008
US

V. Phone/Fax

Practice location:
  • Phone: 760-729-6455
  • Fax: 760-729-6455
Mailing address:
  • Phone: 760-729-6455
  • Fax: 760-729-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberCA PSY 14416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: