Provider Demographics
NPI:1043334675
Name:MATHERSON, MELISSA L (MFT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:L
Last Name:MATHERSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-931-9035
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-791-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46668106H00000X
FLMT2697106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist