Healthcare Provider Details

I. General information

NPI: 1205110137
Provider Name (Legal Business Name): ORETHEA YONTONNA MATTISON D.M., L.C.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7480 CATTERICK CT
WINDSOR MILL MD
21244-5600
US

IV. Provider business mailing address

7480 CATTERICK CT
WINDSOR MILL MD
21244-5600
US

V. Phone/Fax

Practice location:
  • Phone: 443-226-2838
  • Fax:
Mailing address:
  • Phone: 443-226-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA346
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: