MEDICARE: MR. MAYANCE JOSEPH MATHIEU JR. MA., 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	101YM0800X	Mental Health Counselor	4053	LA

General Provider Information

NPI Number	:	1699016428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAYANCE JOSEPH MATHIEU JR. MA., LPC

Provider Business Mailing Address
First Line	:	2733 RUE CANNES DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4044
Country	:	US
Telephone Number	:	337-540-3427
Fax Number	:	337-436-8291

Provider Business Practice Location Address
First Line	:	7378 HIGHWAY 90 E
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70615-4803
Country	:	US
Telephone Number	:	337-436-7553
Fax Number	:	337-436-8291

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

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	03/04/2013

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