Provider Demographics
NPI:1154570604
Name:MATHES, SANDRA JEAN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JEAN
Last Name:MATHES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N SHAMROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-9658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 N SHAMROCK BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802
Practice Address - Country:US
Practice Address - Phone:501-303-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR169-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid
AR5S244Medicare UPIN