Provider Demographics
NPI:1598375735
Name:MATHEWS, TERRY (MED, LAC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:MED, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 W CHANDLER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5286
Mailing Address - Country:US
Mailing Address - Phone:480-779-9050
Mailing Address - Fax:
Practice Address - Street 1:1835 W CHANDLER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5286
Practice Address - Country:US
Practice Address - Phone:480-779-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18725101Y00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor