=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669429767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH GWEN MATHER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 08/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6615 E PACIFIC COAST HWY SUITE #115
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90803-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-596-0090
-----------------------------------------------------
Fax | 562-596-0094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16033 BOLSA CHICA ST SUITE #104-239
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-2452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-846-8230
-----------------------------------------------------
Fax | 714-840-6508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY17113
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------