Provider Demographics
NPI:1770878282
Name:MATTSON, DONALD C (PHD, ATR, LPC)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:C
Last Name:MATTSON
Suffix:
Gender:M
Credentials:PHD, ATR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 TOWER AVE.
Mailing Address - Street 2:STE. 108
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5269
Mailing Address - Country:US
Mailing Address - Phone:715-718-5606
Mailing Address - Fax:
Practice Address - Street 1:3215 TOWER AVE
Practice Address - Street 2:STE. 108
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5388
Practice Address - Country:US
Practice Address - Phone:715-718-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012474101Y00000X
WI5340-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780697078Medicaid