Healthcare Provider Details

I. General information

NPI: 1740689611
Provider Name (Legal Business Name): MEGHAN MATTOS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9225 UNIVERSITY BLVD SUITE E2-A
NORTH CHARLESTON SC
29406-9149
US

IV. Provider business mailing address

9225 UNIVERSITY BLVD SUITE E2-A
NORTH CHARLESTON SC
29406-9149
US

V. Phone/Fax

Practice location:
  • Phone: 843-637-4211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004993
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1347
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: