Provider Demographics
NPI:1942481049
Name:MATHERNE, BRETT L (LAC)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:L
Last Name:MATHERNE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 HIGHT ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-223-4009
Mailing Address - Fax:985-223-7002
Practice Address - Street 1:214 HIGHT ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70361
Practice Address - Country:US
Practice Address - Phone:985-223-4009
Practice Address - Fax:985-223-7002
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA835101YA0400X
LA431251S00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-4503680OtherEIN