Healthcare Provider Details

I. General information

NPI: 1750017968
Provider Name (Legal Business Name): REGINA MARIE MATTRELLA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-2598
US

IV. Provider business mailing address

250 PLEASANT ST
CONCORD NH
03301-2598
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-7200
  • Fax: 603-227-7562
Mailing address:
  • Phone: 603-230-7235
  • Fax: 603-227-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1467
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1467
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: