Provider Demographics
NPI:1275562860
Name:MATHIESON, JOHN (ACSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MATHIESON
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 LAURALWOOD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002
Mailing Address - Country:US
Mailing Address - Phone:226-966-5600
Mailing Address - Fax:269-966-5585
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-1014
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:269-966-5585
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010156761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical