Provider Demographics
NPI:1982323408
Name:CHADWICK MATHIS, CYNTHIA (LSSP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:CHADWICK MATHIS
Suffix:
Gender:F
Credentials:LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N KILGORE ST
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-5825
Mailing Address - Country:US
Mailing Address - Phone:903-988-3900
Mailing Address - Fax:903-983-3212
Practice Address - Street 1:301 N KILGORE ST
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5825
Practice Address - Country:US
Practice Address - Phone:903-988-3900
Practice Address - Fax:903-983-3212
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32605103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32605Medicaid