Provider Demographics
NPI:1871115089
Name:MATHERNE, BERNARD ANTHONY JR (MS,ICADCII)
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:ANTHONY
Last Name:MATHERNE
Suffix:JR
Gender:M
Credentials:MS,ICADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:226 LOWE LN
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-4313
Mailing Address - Country:US
Mailing Address - Phone:601-791-5135
Mailing Address - Fax:601-791-5140
Practice Address - Street 1:226 LOWE LANE
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-4313
Practice Address - Country:US
Practice Address - Phone:601-791-5135
Practice Address - Fax:601-791-5140
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD97-025M101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)