Provider Demographics
NPI:1497287445
Name:MATHESON, LAURA EMMA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EMMA
Last Name:MATHESON
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 1:12638 SE 160TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-4718
Mailing Address - Country:US
Mailing Address - Phone:206-819-8376
Mailing Address - Fax:
Practice Address - Street 1:22500 SE 64TH PL
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8111
Practice Address - Country:US
Practice Address - Phone:253-363-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WALF61188799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program