MEDICARE: ALISA M MATTIAZZI LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW60489586	WA

General Provider Information

NPI Number	:	1700493806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISA M MATTIAZZI LICSW

Provider Business Mailing Address
First Line	:	10006 100TH AVE SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-3124
Country	:	US
Telephone Number	:	503-302-6295
Fax Number	:

Provider Business Practice Location Address
First Line	:	10006 100TH AVE SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-3124
Country	:	US
Telephone Number	:	503-302-6295
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2020
Last Update Date	:	09/23/2020

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