Healthcare Provider Details

I. General information

NPI: 1598114803
Provider Name (Legal Business Name): KAMILAH MATHIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 10/25/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 SANDY LN
FAIRFIELD OH
45014-2738
US

IV. Provider business mailing address

4600 MONTOGMERY RD SUITE 400
CINCINNATI OH
45212
US

V. Phone/Fax

Practice location:
  • Phone: 866-934-7450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161407
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.150697-PRE
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1601004
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: