MEDICARE: MR. DEWEY TRUMAN MATHERLY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C001231	NC
2	1041C0700X	Clinical Social Worker	C001231	NC
3	106H00000X	Marriage & Family Therapist	408	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	54683	OTHER	NC	BC/BS PIN NUMBER

General Provider Information

NPI Number	:	1306889761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEWEY TRUMAN MATHERLY LCSW

Provider Business Mailing Address
First Line	:	151 KINGS CREST CT
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-8218
Country	:	US
Telephone Number	:	704-730-8295
Fax Number	:	704-730-8295

Provider Business Practice Location Address
First Line	:	151 KINGS CREST CT
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-8218
Country	:	US
Telephone Number	:	704-730-8295
Fax Number	:	704-730-8295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	01/25/2013

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