Provider Demographics
NPI:1609210327
Name:MATTHEWS, MONA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:LEE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 SE 138TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4402
Mailing Address - Country:US
Mailing Address - Phone:208-940-2053
Mailing Address - Fax:
Practice Address - Street 1:5907 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6707
Practice Address - Country:US
Practice Address - Phone:208-940-2053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist