Provider Demographics
NPI:1669922647
Name:MATHEW, MARY MALISA
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MALISA
Last Name:MATHEW
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 1:123 KINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4024
Mailing Address - Country:US
Mailing Address - Phone:267-441-5817
Mailing Address - Fax:
Practice Address - Street 1:1725 S NAPERVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5855
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program