Provider Demographics
NPI:1306020813
Name:MATHESON, ELIZABETH ALICE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ALICE
Last Name:MATHESON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ALICE
Other - Last Name:KRANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3660 ROME DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905
Mailing Address - Country:US
Mailing Address - Phone:765-420-0938
Mailing Address - Fax:
Practice Address - Street 1:3660 ROME DRIVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005976A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400015754Medicare PIN