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General NPI Number Information
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NPI Number | 1063782787
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Entity Type | Individual
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Provider Name | TESSA MATTIE
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Gender | Female
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 10/16/2012
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Provider Practice Location Address
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Address Line | 3020 CHILDRENS WAY
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City | SAN DIEGO
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State | CA
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Zip | 92123-4223
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Country | US
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Telephone | 858-966-1700
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Fax |
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Provider Business Mailing Address
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Address Line | 1813 BACON ST
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City | SAN DIEGO
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State | CA
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Zip | 92107-3003
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Country | US
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Telephone | 619-665-1546
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW 24231
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 21480187
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License Number State | CA
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