Provider Demographics
NPI:1518207489
Name:MATHIS, HEATHER (LPC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 CORAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5595
Mailing Address - Country:US
Mailing Address - Phone:770-365-6348
Mailing Address - Fax:
Practice Address - Street 1:190 CAMDEN HILL RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-2448
Practice Address - Country:US
Practice Address - Phone:770-513-8988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008471101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor