Healthcare Provider Details

I. General information

NPI: 1740312248
Provider Name (Legal Business Name): KENNETH P MATHEWSON LMFT, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 NORTH RD
MEDFORD ME
04463-6123
US

IV. Provider business mailing address

781 NORTH RD
MEDFORD ME
04463-6123
US

V. Phone/Fax

Practice location:
  • Phone: 860-305-9249
  • Fax:
Mailing address:
  • Phone: 860-305-9249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000746
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001026
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF4145
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: