Healthcare Provider Details

I. General information

NPI: 1295665834
Provider Name (Legal Business Name): MATTELYNN ELLISE MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SW ARCTIC DR
BEAVERTON OR
97005-9447
US

IV. Provider business mailing address

410 NE DEKUM ST APT 401
PORTLAND OR
97211-2982
US

V. Phone/Fax

Practice location:
  • Phone: 458-219-5557
  • Fax:
Mailing address:
  • Phone: 458-219-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: