Provider Demographics
NPI:1477044261
Name:MATHSON, AUDREY NOELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:NOELLE
Last Name:MATHSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:GLENROCK
Mailing Address - State:WY
Mailing Address - Zip Code:82637-0786
Mailing Address - Country:US
Mailing Address - Phone:307-436-9206
Mailing Address - Fax:307-436-9730
Practice Address - Street 1:925 W. BIRCH ST
Practice Address - Street 2:
Practice Address - City:GLENROCK
Practice Address - State:WY
Practice Address - Zip Code:82637
Practice Address - Country:US
Practice Address - Phone:307-436-9206
Practice Address - Fax:307-436-9730
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1041C0700XMedicaid
WY1123OtherLCSW