Provider Demographics
NPI:1467400762
Name:MATHESON, MARIE CHRISTINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:CHRISTINE
Last Name:MATHESON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 SANTA MONICA BLVD
Mailing Address - Street 2:STE 504
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2767
Mailing Address - Country:US
Mailing Address - Phone:310-317-1233
Mailing Address - Fax:310-457-5055
Practice Address - Street 1:28809 BONIFACE DR
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4205
Practice Address - Country:US
Practice Address - Phone:310-317-1233
Practice Address - Fax:310-457-5055
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16907103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15156Medicare UPIN
CP16907Medicare ID - Type Unspecified