Provider Demographics
NPI:1215711395
Name:MATTESON, COURTENEY CLUNE
Entity type:Individual
Prefix:
First Name:COURTENEY
Middle Name:CLUNE
Last Name:MATTESON
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 1:70 STONEY BATTERY RD
Mailing Address - Street 2:
Mailing Address - City:EARLEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21919-1009
Mailing Address - Country:US
Mailing Address - Phone:410-920-4555
Mailing Address - Fax:
Practice Address - Street 1:216 E PULASKI HWY STE 212
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6589
Practice Address - Country:US
Practice Address - Phone:302-384-7843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health