Provider Demographics
NPI:1497882815
Name:MATHISEN, KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MATHISEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 OMNI DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-4527
Mailing Address - Country:US
Mailing Address - Phone:908-359-0760
Mailing Address - Fax:908-359-5356
Practice Address - Street 1:407 OMNI DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-4527
Practice Address - Country:US
Practice Address - Phone:908-359-0760
Practice Address - Fax:908-359-5356
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00199600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ584956Medicare ID - Type Unspecified