Provider Demographics
NPI:1740312248
Name:MATHEWSON, KENNETH P (LMFT, LADC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:P
Last Name:MATHEWSON
Suffix:
Gender:M
Credentials:LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04463-6123
Mailing Address - Country:US
Mailing Address - Phone:860-305-9249
Mailing Address - Fax:
Practice Address - Street 1:781 NORTH RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:ME
Practice Address - Zip Code:04463-6123
Practice Address - Country:US
Practice Address - Phone:860-305-9249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000746101YA0400X
CT001026106H00000X
MEMF4145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)