Provider Demographics
NPI:1518687300
Name:MATHIS, DONTAE EUGENE SR
Entity Type:Individual
Prefix:
First Name:DONTAE
Middle Name:EUGENE
Last Name:MATHIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3854 SW CULLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3528
Mailing Address - Country:US
Mailing Address - Phone:971-263-7239
Mailing Address - Fax:
Practice Address - Street 1:124 E HISTORIC COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060
Practice Address - Country:US
Practice Address - Phone:971-293-9237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator