Provider Demographics
NPI:1154068245
Name:MATHEWS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:524 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2151
Mailing Address - Country:US
Mailing Address - Phone:309-736-7170
Mailing Address - Fax:309-736-7150
Practice Address - Street 1:524 15TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-2151
Practice Address - Country:US
Practice Address - Phone:309-736-7170
Practice Address - Fax:309-736-7150
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor