Provider Demographics
NPI:1083035182
Name:MATHEWS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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:P.O. BOX 800
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-4705
Practice Address - Street 1:850 W. MAPLE ST.
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-4705
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013040148103TC0700X
WAPY61048865103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical