Provider Demographics
NPI:1124766753
Name:MATHIS, ANDREA RENEE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:RENEE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 WALNUT HILL LN STE 130
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4418
Mailing Address - Country:US
Mailing Address - Phone:214-750-1207
Mailing Address - Fax:214-750-8504
Practice Address - Street 1:8210 WALNUT HILL LN STE 130
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4418
Practice Address - Country:US
Practice Address - Phone:214-750-1207
Practice Address - Fax:214-750-8504
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1365389225100000X
TNCP024762T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist