Provider Demographics
NPI:1174380166
Name:MATHIESEN, MARIEL (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:MATHIESEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 RENA CT
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7150
Mailing Address - Country:US
Mailing Address - Phone:609-738-5305
Mailing Address - Fax:
Practice Address - Street 1:9 HOSPITAL DR STE A20
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6425
Practice Address - Country:US
Practice Address - Phone:732-829-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01205400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist