Provider Demographics
NPI:1023157914
Name:MATHEWS, MARSHA DIANE (MFT)
Entity type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:DIANE
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24130 ROSITA DR
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7982
Mailing Address - Country:US
Mailing Address - Phone:760-822-1516
Mailing Address - Fax:
Practice Address - Street 1:31772 CASINO DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4502
Practice Address - Country:US
Practice Address - Phone:951-899-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist