Healthcare Provider Details

I. General information

NPI: 1972914257
Provider Name (Legal Business Name): RYAN MATTSON MI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 HIGHLAND BLVD
BOZEMAN MT
59715-6902
US

IV. Provider business mailing address

915 HIGHLAND BLVD
BOZEMAN MT
59715-6902
US

V. Phone/Fax

Practice location:
  • Phone: 406-414-5000
  • Fax:
Mailing address:
  • Phone: 406-414-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: