Provider Demographics
NPI:1093049199
Name:MATHIS, WILLIAM RICHARD (MA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 PINELAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-9212
Mailing Address - Country:US
Mailing Address - Phone:910-258-7796
Mailing Address - Fax:
Practice Address - Street 1:171 COMTECH DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7270
Practice Address - Country:US
Practice Address - Phone:910-736-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0537101Y00000X, 103K00000X, 103T00000X, 103TM1800X
NC537103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities