Healthcare Provider Details

I. General information

NPI: 1932631116
Provider Name (Legal Business Name): MATTISON THERAPEUTIC CONSULTING AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 E REDONDO AVE
SALT LAKE CITY UT
84105-3028
US

IV. Provider business mailing address

667 E REDONDO AVE
SALT LAKE CITY UT
84105-3028
US

V. Phone/Fax

Practice location:
  • Phone: 205-612-0902
  • Fax:
Mailing address:
  • Phone: 205-612-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10186313-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10186313-6004
License Number StateUT

VIII. Authorized Official

Name: CLAIRE MATTISON
Title or Position: OWNER/THERAPIST
Credential: CMHC
Phone: 205-612-0902