Provider Demographics
NPI:1891242772
Name:MATHESON, ELLEN J (MS, CNS, LMT)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:J
Last Name:MATHESON
Suffix:
Gender:F
Credentials:MS, CNS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2948 CATHEDRAL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7309
Mailing Address - Country:US
Mailing Address - Phone:843-324-5736
Mailing Address - Fax:
Practice Address - Street 1:621 WAPPOO RD
Practice Address - Street 2:SEED OF LIFE COLLECTIVE
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-1800
Practice Address - Country:US
Practice Address - Phone:843-410-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6744172M00000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No172M00000XOther Service ProvidersMechanotherapist