Provider Demographics
NPI:1508362195
Name:MATHIS, NICHOLAS IAN (ACMHC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:IAN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-5131
Mailing Address - Country:US
Mailing Address - Phone:801-739-5894
Mailing Address - Fax:
Practice Address - Street 1:327 W GORDON AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2381
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT280269-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician