Provider Demographics
NPI:1245505577
Name:WILSON MATHEWS, DIVYA (MS)
Entity type:Individual
Prefix:MISS
First Name:DIVYA
Middle Name:
Last Name:WILSON MATHEWS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8091 TOWNSHIP LINE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2494
Mailing Address - Country:US
Mailing Address - Phone:317-415-7742
Mailing Address - Fax:
Practice Address - Street 1:8091 TOWNSHIP LINE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2494
Practice Address - Country:US
Practice Address - Phone:317-415-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99049858A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS