=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457718744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATHENY THERAPY & CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2016
-----------------------------------------------------
Last Update Date | 01/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5241 N SHORE DR
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55804-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-296-9429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5241 N SHORE DR
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55804-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-296-9429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SAPRINA ANN MATHENY
-----------------------------------------------------
Credential | MSW, LICSW
-----------------------------------------------------
Telephone | 715-296-9429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 16047
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------