=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376901835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELA L. CHRISTMAS-MATTISON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2016
-----------------------------------------------------
Last Update Date | 01/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 HUBBLE ST
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13142-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-298-6535
-----------------------------------------------------
Fax | 315-298-6535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 755
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13142-0755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-298-6535
-----------------------------------------------------
Fax | 315-298-6535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELA L. CHRISTMAS-MATTISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-298-6535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------