Provider Demographics
NPI:1093065682
Name:MATHIESEN, TABETHA NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TABETHA
Middle Name:NICOLE
Last Name:MATHIESEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:TABETHA
Other - Middle Name:NICOLE
Other - Last Name:KRAEUTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:205 E CIMARRON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:OK
Mailing Address - Zip Code:73028-9296
Mailing Address - Country:US
Mailing Address - Phone:405-795-7110
Mailing Address - Fax:
Practice Address - Street 1:205 E CIMARRON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT
Practice Address - State:OK
Practice Address - Zip Code:73028-9296
Practice Address - Country:US
Practice Address - Phone:405-795-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3775235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist