MEDICARE: JANET MARIE MATHESON MS LPC

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	101Y00000X	Counselor	1185	OK

General Provider Information

NPI Number	:	1669532792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANET MARIE MATHESON MS LPC

Provider Business Mailing Address
First Line	:	1918 LAKE ROAD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-1918
Country	:	US
Telephone Number	:	580-765-2639
Fax Number	:	580-765-2581

Provider Business Practice Location Address
First Line	:	1918 LAKE ROAD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-1918
Country	:	US
Telephone Number	:	580-765-2639
Fax Number	:	580-765-2581

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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