Provider Demographics
NPI:1730065202
Name:MATTSON, DAKOTA JEAN
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:JEAN
Last Name:MATTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1800
Mailing Address - Country:US
Mailing Address - Phone:517-270-2619
Mailing Address - Fax:
Practice Address - Street 1:1434 W CHICAGO BLVD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-8727
Practice Address - Country:US
Practice Address - Phone:517-507-5556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician