Provider Demographics
NPI:1992063747
Name:MATHIS, DEBORAH M (LSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 DYERS COVE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08345-2000
Mailing Address - Country:US
Mailing Address - Phone:856-447-9709
Mailing Address - Fax:
Practice Address - Street 1:1038 E CHESTNUT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5800
Practice Address - Country:US
Practice Address - Phone:856-507-2735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05730300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker