Provider Demographics
NPI:1144972936
Name:MATHESON, MIKAYLA
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:MATHESON
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 1:99 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-2648
Mailing Address - Country:US
Mailing Address - Phone:781-733-0232
Mailing Address - Fax:
Practice Address - Street 1:80 WASHINGTON ST STE P55
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1742
Practice Address - Country:US
Practice Address - Phone:781-290-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty