Provider Demographics
NPI:1790218196
Name:MATTHEWS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 E MOUNT PLEASANT RD APT 504
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-5928
Mailing Address - Country:US
Mailing Address - Phone:225-361-4723
Mailing Address - Fax:
Practice Address - Street 1:1233 E MOUNT PLEASANT RD APT 504
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791
Practice Address - Country:US
Practice Address - Phone:225-361-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA000000Medicaid