Provider Demographics
NPI:1093467169
Name:MATTIS, TASHANA NATASHA (LSW)
Entity Type:Individual
Prefix:
First Name:TASHANA
Middle Name:NATASHA
Last Name:MATTIS
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 1:5104 S KIMBARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3915
Mailing Address - Country:US
Mailing Address - Phone:727-637-1285
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 501
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4530
Practice Address - Country:US
Practice Address - Phone:773-888-3361
Practice Address - Fax:773-897-5766
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID150.106199104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker