Healthcare Provider Details

I. General information

NPI: 1275562860
Provider Name (Legal Business Name): JOHN MATHIESON ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 ARMSTRONG RD
BATTLE CREEK MI
49015-1014
US

IV. Provider business mailing address

1926 LAURALWOOD
PORTAGE MI
49002
US

V. Phone/Fax

Practice location:
  • Phone: 269-966-5600
  • Fax: 269-966-5585
Mailing address:
  • Phone: 226-966-5600
  • Fax: 269-966-5585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801015676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: