Provider Demographics
NPI:1255015962
Name:MAYES, MATHEW AVERY (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:AVERY
Last Name:MAYES
Suffix:
Gender:M
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-652-1004
Mailing Address - Fax:
Practice Address - Street 1:1205 S 70TH ST, STE. 301
Practice Address - Street 2:1205
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3167
Practice Address - Country:US
Practice Address - Phone:414-531-5207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7265-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor