Basic Information
| Provider Information | |||||||||
| NPI: | 1073275749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHER | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 E HIGHLAND AVE APT 39 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022909207 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 635 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850426583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0224372776 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2021 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-19543 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.