MEDICARE: MR. KENNETH P MATHEWSON LMFT, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	000746	CT
2	106H00000X	Marriage & Family Therapist	001026	CT
3	106H00000X	Marriage & Family Therapist	MF4145	ME

General Provider Information

NPI Number	:	1740312248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH P MATHEWSON LMFT, LADC

Provider Business Mailing Address
First Line	:	781 NORTH RD
Second Line	:
City	:	MEDFORD
State	:	ME
Zip	:	04463-6123
Country	:	US
Telephone Number	:	860-305-9249
Fax Number	:

Provider Business Practice Location Address
First Line	:	781 NORTH RD
Second Line	:
City	:	MEDFORD
State	:	ME
Zip	:	04463-6123
Country	:	US
Telephone Number	:	860-305-9249
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	05/29/2013

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