1467400762 NPI number — DR. MARIE CHRISTINE MATHESON PHD

Table of content: DR. MARIE CHRISTINE MATHESON PHD (NPI 1467400762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467400762 NPI number — DR. MARIE CHRISTINE MATHESON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHESON
Provider First Name:
MARIE
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467400762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11901 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
STE 504
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-2767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-317-1233
Provider Business Mailing Address Fax Number:
310-457-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28809 BONIFACE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALIBU
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90265-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-317-1233
Provider Business Practice Location Address Fax Number:
310-457-5055
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY16907 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103G00000X , with the licence number: PSY16907 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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