Provider Demographics
NPI:1396583456
Name:MATHEWS, MIRISSA BONITA
Entity type:Individual
Prefix:
First Name:MIRISSA
Middle Name:BONITA
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7941 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1953
Mailing Address - Country:US
Mailing Address - Phone:317-726-2121
Mailing Address - Fax:
Practice Address - Street 1:11636 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001-8758
Practice Address - Country:US
Practice Address - Phone:812-926-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99122333A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker