Provider Demographics
NPI:1861844094
Name:MATHEWS, EDWARD (ISAS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:ISAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 CONSTITUTION WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3565
Mailing Address - Country:US
Mailing Address - Phone:208-932-4493
Mailing Address - Fax:208-932-4582
Practice Address - Street 1:482 CONSTITUTION WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3565
Practice Address - Country:US
Practice Address - Phone:208-932-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDISAS-10328101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)