Provider Demographics
NPI:1558391144
Name:MATTHEWS, MARTHA LEE (RN, PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LEE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:RN, PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2403
Mailing Address - Country:US
Mailing Address - Phone:812-336-0168
Mailing Address - Fax:
Practice Address - Street 1:421 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2403
Practice Address - Country:US
Practice Address - Phone:812-336-0168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001205A101YM0800X
IN20041513A103TC1900X
IN28043229A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN252770BBMedicare PIN
INP36252Medicare UPIN