Basic Information
| Provider Information | |||||||||
| NPI: | 1598863680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTISON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3770 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078229122 | ||||||||
| FaxNumber: | 7078221969 | ||||||||
| Practice Location | |||||||||
| Address1: | 3770 JANES RD | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078229122 | ||||||||
| FaxNumber: | 7078221969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AU 301 | CA | X | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | HA 954 | CA | X | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.