Basic Information
| Provider Information | |||||||||
| NPI: | 1407405772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHERNE | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 BIRNEY ST | ||||||||
| Address2: | |||||||||
| City: | ESSEXVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487321671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343895218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3175 PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487062823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896673377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2019 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6801113569 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.