Provider Demographics
NPI:1033647094
Name:MATHEWS, KRISTY DANIELLE
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:DANIELLE
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 BROADWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1335
Mailing Address - Country:US
Mailing Address - Phone:732-852-7373
Mailing Address - Fax:732-631-8136
Practice Address - Street 1:1049 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1335
Practice Address - Country:US
Practice Address - Phone:732-852-7373
Practice Address - Fax:732-631-8136
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00681500101Y00000X
NJ37AC00346700101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty