Provider Demographics
NPI:1528677887
Name:MATHIS, CALLIE MAE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:MAE
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 1:4359 TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1533
Mailing Address - Country:US
Mailing Address - Phone:314-752-2022
Mailing Address - Fax:
Practice Address - Street 1:4359 TAFT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1533
Practice Address - Country:US
Practice Address - Phone:314-752-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019046398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist