Provider Demographics
NPI:1194584086
Name:MATHIS, RENE MARTIN (LCSW)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:MARTIN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 212974
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91921-2974
Mailing Address - Country:US
Mailing Address - Phone:619-829-6583
Mailing Address - Fax:
Practice Address - Street 1:2274 ELROD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145-0001
Practice Address - Country:US
Practice Address - Phone:619-829-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1122581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical