Provider Demographics
NPI:1093296261
Name:KENDRA A MATHYS PSYD LLC
Entity Type:Organization
Organization Name:KENDRA A MATHYS PSYD LLC
Other - Org Name:LAKEWOOD WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHYS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:440-202-1708
Mailing Address - Street 1:15644 MADISON AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5622
Mailing Address - Country:US
Mailing Address - Phone:440-202-1708
Mailing Address - Fax:440-287-9707
Practice Address - Street 1:15644 MADISON AVE STE 202
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5622
Practice Address - Country:US
Practice Address - Phone:440-202-1708
Practice Address - Fax:440-287-9707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.7357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty