Provider Demographics
NPI:1275062366
Name:MATHEWS, DORENE LOIS (LMSW)
Entity Type:Individual
Prefix:
First Name:DORENE
Middle Name:LOIS
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4435 SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MORAN
Mailing Address - State:MI
Mailing Address - Zip Code:49760-0124
Mailing Address - Country:US
Mailing Address - Phone:906-280-0845
Mailing Address - Fax:
Practice Address - Street 1:799 HOMBACH ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1735
Practice Address - Country:US
Practice Address - Phone:906-984-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010778611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801077861Medicaid