Healthcare Provider Details

I. General information

NPI: 1245038017
Provider Name (Legal Business Name): DERRIK HUNTER MATTOX-HANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SE WASHINGTON AVE
CHEHALIS WA
98532-3058
US

IV. Provider business mailing address

PO BOX 141106
SPOKANE VALLEY WA
99214-1106
US

V. Phone/Fax

Practice location:
  • Phone: 360-507-8032
  • Fax:
Mailing address:
  • Phone: 509-232-5766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61605542
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: