Provider Demographics
NPI:1740622828
Name:MATHESON, LORI ANN (LLPC)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:MATHESON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:MATHESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:634 FINCH CT
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3041
Mailing Address - Country:US
Mailing Address - Phone:248-274-4463
Mailing Address - Fax:
Practice Address - Street 1:634 FINCH CT
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3041
Practice Address - Country:US
Practice Address - Phone:248-274-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional