Provider Demographics
NPI:1497024780
Name:MATHENGE, LATREESE WYSHAWN
Entity Type:Individual
Prefix:MS
First Name:LATREESE
Middle Name:WYSHAWN
Last Name:MATHENGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MERDIAN SUITE 408
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7220
Mailing Address - Country:US
Mailing Address - Phone:405-528-4673
Mailing Address - Fax:
Practice Address - Street 1:900 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7220
Practice Address - Country:US
Practice Address - Phone:405-528-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation