Healthcare Provider Details

I. General information

NPI: 1639683477
Provider Name (Legal Business Name): JULIE MATHENEY MS, CCC-SLP, CLEC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 N LAS PALMAS AVE
LOS ANGELES CA
90068-4101
US

IV. Provider business mailing address

1922 N LAS PALMAS AVE
LOS ANGELES CA
90068-4101
US

V. Phone/Fax

Practice location:
  • Phone: 616-822-1812
  • Fax:
Mailing address:
  • Phone: 616-822-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: