Provider Demographics
NPI:1740762608
Name:MATHEW, ALICIA CORAL
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:CORAL
Last Name:MATHEW
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 1:1900 KILDAIRE FARM ROAD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:OH
Mailing Address - Zip Code:27551
Mailing Address - Country:US
Mailing Address - Phone:919-350-4018
Mailing Address - Fax:
Practice Address - Street 1:1900 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6616
Practice Address - Country:US
Practice Address - Phone:919-350-4018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0077081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical