Provider Demographics
NPI:1093276032
Name:MATHEWS, MARTIN (TCDAC, LCDCIII)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:TCDAC, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3369
Mailing Address - Country:US
Mailing Address - Phone:859-444-4499
Mailing Address - Fax:859-916-6713
Practice Address - Street 1:1450 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3369
Practice Address - Country:US
Practice Address - Phone:859-444-4499
Practice Address - Fax:859-916-6713
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246664101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03213Medicaid