Provider Demographics
NPI:1306203823
Name:MATHEWS, KYLE (BS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HASTINGS ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3445
Mailing Address - Country:US
Mailing Address - Phone:231-947-8110
Mailing Address - Fax:
Practice Address - Street 1:1000 HASTINGS ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3445
Practice Address - Country:US
Practice Address - Phone:231-947-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker