Provider Demographics
NPI:1518648476
Name:MATHIS, DIANA (LCSW-26440)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LCSW-26440
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MATHIS, LCSW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-26440
Mailing Address - Street 1:P O BOX 840-180
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-7878
Mailing Address - Country:US
Mailing Address - Phone:760-232-6706
Mailing Address - Fax:
Practice Address - Street 1:26734 JORDAN RD
Practice Address - Street 2:
Practice Address - City:HELENDALE
Practice Address - State:CA
Practice Address - Zip Code:92342-7878
Practice Address - Country:US
Practice Address - Phone:760-232-6706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA264401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical