| Doctor Name: | MS. KATHLEEN G. MATTIS |
| NPI Number: | 1790040004 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | 077293 |
| Business Practice Address: | 29 William Manor Dr Waddington, NY - 136943186 |
| Business Phone Number: | 3153883074 |
| Business Fax Number: | |
| Mailing Address: | 29 William Manor Dr, WADDINGTON |
| State: | NY |
| Postal Code: | 136943186 |
| Phone Number: | 3153883074 |
| Fax Number: | |
| NPI Enumeration Date: | 07/12/2012 |
| NPI Last Update Date: | 07/12/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 077293 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |