Provider Demographics
NPI:1093474298
Name:MATHEWS, ATTICUS JAMES
Entity Type:Individual
Prefix:
First Name:ATTICUS
Middle Name:JAMES
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 NW MADISCHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1221
Mailing Address - Country:US
Mailing Address - Phone:580-492-3614
Mailing Address - Fax:
Practice Address - Street 1:8501 NW MADISCHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1221
Practice Address - Country:US
Practice Address - Phone:580-492-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKNAOtherPEER RECOVERY SUPPORT SPECIALIST