Provider Demographics
NPI:1164709051
Name:MATHESON, AMY NICOLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:MATHESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 MARTIN L KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-4135
Mailing Address - Country:US
Mailing Address - Phone:559-442-0400
Mailing Address - Fax:559-442-0401
Practice Address - Street 1:2302 MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-4135
Practice Address - Country:US
Practice Address - Phone:559-442-0400
Practice Address - Fax:559-442-0401
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)