Healthcare Provider Details

I. General information

NPI: 1891225355
Provider Name (Legal Business Name): LISA MATTEY RADT 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RANCHEROS DR STE 16
SAN MARCOS CA
92069-2900
US

IV. Provider business mailing address

340 RANCHEROS DR STE 16
SAN MARCOS CA
92069-2900
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax:
Mailing address:
  • Phone: 760-744-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: