Basic Information
| Provider Information | |||||||||
| NPI: | 1053769505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIESON | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IBECHEM | ||||||||
| OtherFirstName: | CINDY | ||||||||
| OtherMiddleName: | MATHIESON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 40 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044017144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079454240 | ||||||||
| FaxNumber: | 2079903660 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044017144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079454240 | ||||||||
| FaxNumber: | 2079903660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | XL4275 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.