Provider Demographics
NPI:1447310974
Name:MATTSON, PATTY JEAN (MS)
Entity type:Individual
Prefix:MRS
First Name:PATTY
Middle Name:JEAN
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8055 E ECHO CANYON ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-7185
Mailing Address - Country:US
Mailing Address - Phone:480-777-5907
Mailing Address - Fax:
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3307
Practice Address - Country:US
Practice Address - Phone:480-472-0734
Practice Address - Fax:480-472-0892
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ580044Medicaid
AZSLP0143OtherDHS LICENSE SLP