Provider Demographics
NPI:1013043041
Name:MATHERNE, J. DONALD (PHD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:DONALD
Last Name:MATHERNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180B DEBUYS RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4407
Mailing Address - Country:US
Mailing Address - Phone:228-385-1827
Mailing Address - Fax:228-385-1127
Practice Address - Street 1:180B DEBUYS RD STE 202
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4407
Practice Address - Country:US
Practice Address - Phone:228-385-1827
Practice Address - Fax:228-385-1127
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS#78103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110990Medicaid