Healthcare Provider Details

I. General information

NPI: 1982908471
Provider Name (Legal Business Name): CHRISTINA MARIE MATTISE OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PALM BEACH RD
STUART FL
34994-4044
US

IV. Provider business mailing address

2097 SE FERN PARK DR
PORT ST LUCIE FL
34952-8005
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-1860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 10807
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: