Healthcare Provider Details

I. General information

NPI: 1447128368
Provider Name (Legal Business Name): CARRIE B MATTOX MSP, SUDCCIV/MATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax:
Mailing address:
  • Phone: 559-229-9040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: