Provider Demographics
NPI:1205161171
Name:MATTISON, RUSSELL V (BCBA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:V
Last Name:MATTISON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BENJAMIN DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-1945
Mailing Address - Country:US
Mailing Address - Phone:610-316-7307
Mailing Address - Fax:610-436-1208
Practice Address - Street 1:207 N BENJAMIN DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-1945
Practice Address - Country:US
Practice Address - Phone:610-316-7307
Practice Address - Fax:610-436-1208
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-05-2337OtherBEHAVIOR ANALYST CERTIFICATION BOARD