Provider Demographics
NPI:1306889761
Name:MATHERLY, DEWEY TRUMAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:DEWEY
Middle Name:TRUMAN
Last Name:MATHERLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KINGS CREST CT
Mailing Address - Street 2:
Mailing Address - City:KINGS MTN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-8218
Mailing Address - Country:US
Mailing Address - Phone:704-730-8295
Mailing Address - Fax:704-730-8295
Practice Address - Street 1:151 KINGS CREST CT
Practice Address - Street 2:
Practice Address - City:KINGS MTN
Practice Address - State:NC
Practice Address - Zip Code:28086-8218
Practice Address - Country:US
Practice Address - Phone:704-730-8295
Practice Address - Fax:704-730-8295
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC001231101YM0800X, 1041C0700X
NC408106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002095Medicaid
NC54683OtherBC/BS PIN NUMBER