Basic Information
| Provider Information | |||||||||
| NPI: | 1356793095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHENY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLEDSOE | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 609 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261430609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042753301 | ||||||||
| FaxNumber: | 3042754798 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042731033 | ||||||||
| FaxNumber: | 3042731034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1241 | WV | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 1241 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1356793095 | 05 | WV | MEDICAID |