Basic Information
| Provider Information | |||||||||
| NPI: | 1366541039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTERA | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 453 MOUNT PLEASANT RD | ||||||||
| Address2: | |||||||||
| City: | HARRISVILLE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028301720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017657599 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 JOHN A CUMMINGS WAY | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDP00159 | RI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | MCH00140 | RI | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 407700 | 01 | RI | BLUE CHIP | OTHER | CM26347 | 05 | RI | MEDICAID | 6252869 | 01 | RI | UNITED HEALTH | OTHER | 0000030461 | 01 | RI | BLUE CROSS | OTHER |