Provider Demographics
NPI:1376078824
Name:MATHIE, TEAL
Entity Type:Individual
Prefix:
First Name:TEAL
Middle Name:
Last Name:MATHIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E LOMBARDY DR
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-2231
Mailing Address - Country:US
Mailing Address - Phone:517-803-6137
Mailing Address - Fax:
Practice Address - Street 1:1114 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9164
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist