Healthcare Provider Details

I. General information

NPI: 1467400762
Provider Name (Legal Business Name): MARIE CHRISTINE MATHESON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28809 BONIFACE DR
MALIBU CA
90265-4205
US

IV. Provider business mailing address

11901 SANTA MONICA BLVD STE 504
LOS ANGELES CA
90025-2767
US

V. Phone/Fax

Practice location:
  • Phone: 310-317-1233
  • Fax: 310-457-5055
Mailing address:
  • Phone: 310-317-1233
  • Fax: 310-457-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY16907
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY16907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: