Basic Information
| Provider Information | |||||||||
| NPI: | 1639525090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTSON | ||||||||
| FirstName: | LORA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Practice Location | |||||||||
| Address1: | 2035 CHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | OTTUMWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2016 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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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 | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.