Provider Demographics
NPI:1144422619
Name:MATHIS, SUE A (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:A
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:A
Other - Last Name:TRUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76703-0890
Mailing Address - Country:US
Mailing Address - Phone:254-752-3451
Mailing Address - Fax:
Practice Address - Street 1:110 S 12TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1810
Practice Address - Country:US
Practice Address - Phone:254-752-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20298101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional