Provider Demographics
NPI:1063782787
Name:MATTIE, TESSA
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:MATTIE
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 1:1813 BACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3003
Mailing Address - Country:US
Mailing Address - Phone:619-665-1546
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 24231101YM0800X
CA21480187104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health