Provider Demographics
NPI:1154546513
Name:MATTOX, MARY A
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MATTOX
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:PO BOX 6221
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86446-6221
Mailing Address - Country:US
Mailing Address - Phone:928-768-4216
Mailing Address - Fax:
Practice Address - Street 1:8450 OLIVE AVE
Practice Address - Street 2:MOHAVE VALLEY ELEM. SD16
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440-9214
Practice Address - Country:US
Practice Address - Phone:928-768-2507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816431Medicaid