Provider Demographics
NPI:1902978109
Name:MATTSON-CHARNLEY, INGRID ELISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:ELISE
Last Name:MATTSON-CHARNLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 CENTRE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1933
Mailing Address - Country:US
Mailing Address - Phone:617-327-5535
Mailing Address - Fax:617-327-7696
Practice Address - Street 1:1895 CENTRE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1933
Practice Address - Country:US
Practice Address - Phone:617-327-5535
Practice Address - Fax:617-327-7696
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7722103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical