Provider Demographics
NPI:1285000893
Name:MATHENY, MATTHEW (LSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MATHENY
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 1/2 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2265
Mailing Address - Country:US
Mailing Address - Phone:313-495-6503
Mailing Address - Fax:
Practice Address - Street 1:514 1/2 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2265
Practice Address - Country:US
Practice Address - Phone:313-495-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150014269104100000X
MI6801096221104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker