Basic Information
| Provider Information | |||||||||
| NPI: | 1073552790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTIA | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 SYLVANWOOD DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480853126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488284306 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30701 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482889333 | ||||||||
| FaxNumber: | 2482881362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6801066583 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.