Provider Demographics
NPI:1154372191
Name:MATHIESEN, MICHELLE A (LICSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:MATHIESEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-3819
Mailing Address - Country:US
Mailing Address - Phone:401-885-3108
Mailing Address - Fax:
Practice Address - Street 1:2343 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-4703
Practice Address - Country:US
Practice Address - Phone:401-333-5999
Practice Address - Fax:401-333-5988
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW016891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1032430OtherNEIGHBORHOOD HEALTH PLAN
RI29590-9OtherBLUE CROSS/BLUE SHIELD
RI412646OtherBLUE CHIP
RIMM54608Medicaid
RIMM59098Medicaid