MEDICARE: KAIYA MATTESON

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1942084348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAIYA MATTESON

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1937 W TOMBSTONE TRL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-1712
Country	:	US
Telephone Number	:	602-327-0125
Fax Number	:

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

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	06/21/2024

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Directions to “ KAIYA MATTESON ” Practice Location

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