Provider Demographics
NPI:1053462465
Name:MATHIS, LAURA L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N DEARBORN ST
Mailing Address - Street 2:#2007
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-1616
Mailing Address - Country:US
Mailing Address - Phone:312-218-7409
Mailing Address - Fax:
Practice Address - Street 1:77 W WASHINGTON ST
Practice Address - Street 2:#1911
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2801
Practice Address - Country:US
Practice Address - Phone:312-218-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636351OtherBLUECROSS BLUESHIELD PPO