Healthcare Provider Details

I. General information

NPI: 1588761902
Provider Name (Legal Business Name): SUSAN MARIE MATTISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 CHIEF RD
BRETHREN MI
49619-9781
US

IV. Provider business mailing address

4539 CHIEF RD
BRETHREN MI
49619-9781
US

V. Phone/Fax

Practice location:
  • Phone: 231-477-5155
  • Fax:
Mailing address:
  • Phone: 231-477-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: