Provider Demographics
NPI:1407044134
Name:MATHEWS, THERESE L (PLP)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:L
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:PLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985459 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-5459
Mailing Address - Country:US
Mailing Address - Phone:402-559-8643
Mailing Address - Fax:
Practice Address - Street 1:985459 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-5459
Practice Address - Country:US
Practice Address - Phone:402-559-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE316103T00000X
NE105079363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025287200Medicaid
NE470855757Medicaid
NE10025287200Medicaid