Healthcare Provider Details

I. General information

NPI: 1043245632
Provider Name (Legal Business Name): NANCY NONE MATTOX LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 ELM CREEK DR
MANAKIN SABOT VA
23103-3165
US

IV. Provider business mailing address

422 ELM CREEK DR
MANAKIN SABOT VA
23103-3165
US

V. Phone/Fax

Practice location:
  • Phone: 804-784-1291
  • Fax: 804-354-2536
Mailing address:
  • Phone: 804-784-1291
  • Fax: 804-354-2536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001316
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: