Provider Demographics
NPI:1063190924
Name:MATHESON, MARY KATHLEEN (MA, CCCSLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:MATHESON
Suffix:
Gender:F
Credentials:MA, CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7504 VOLCLAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1218
Mailing Address - Country:US
Mailing Address - Phone:619-354-8604
Mailing Address - Fax:
Practice Address - Street 1:7504 VOLCLAY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-1218
Practice Address - Country:US
Practice Address - Phone:619-354-8604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty