Provider Demographics
NPI:1104919356
Name:MATHEWS, KATHLEEN ANN (LICSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4959 OLSON MEMORIAL HWY STE B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5159
Mailing Address - Country:US
Mailing Address - Phone:612-978-3209
Mailing Address - Fax:763-270-5915
Practice Address - Street 1:4959 OLSON MEMORIAL HWY STE B
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5159
Practice Address - Country:US
Practice Address - Phone:763-432-4071
Practice Address - Fax:763-432-4073
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002341OtherMEDICARE PTAN
MN917026000Medicaid