Provider Demographics
NPI:1679301170
Name:MATHESON, LISA
Entity type:Individual
Prefix:
First Name:LISA
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 1:201 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4460
Mailing Address - Country:US
Mailing Address - Phone:712-363-7819
Mailing Address - Fax:
Practice Address - Street 1:201 E 11TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4460
Practice Address - Country:US
Practice Address - Phone:712-363-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist