Provider Demographics
NPI:1679787519
Name:MATTSON, SANDRA GAY (LCSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:GAY
Last Name:MATTSON
Suffix:
Gender:F
Credentials:LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 JIM CLARK RD
Mailing Address - Street 2:
Mailing Address - City:PELION
Mailing Address - State:SC
Mailing Address - Zip Code:29123
Mailing Address - Country:US
Mailing Address - Phone:803-894-9796
Mailing Address - Fax:
Practice Address - Street 1:7621 LITTLE AVE STE 420
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8368
Practice Address - Country:US
Practice Address - Phone:704-541-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94881041C0700X
FLSW78971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical