Provider Demographics
NPI:1396355541
Name:MATHIS, ELICIA MARIE
Entity type:Individual
Prefix:
First Name:ELICIA
Middle Name:MARIE
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 1:7556 US HIGHWAY 70
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2686
Mailing Address - Country:US
Mailing Address - Phone:901-552-3497
Mailing Address - Fax:574-635-9228
Practice Address - Street 1:7556 US HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-2686
Practice Address - Country:US
Practice Address - Phone:901-552-3497
Practice Address - Fax:574-635-9228
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health