Provider Demographics
NPI:1528042215
Name:MATHIS, BETTY JEAN (PHD)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JEAN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 RIVERSIDE DR
Mailing Address - Street 2:STE 310
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2544
Mailing Address - Country:US
Mailing Address - Phone:818-386-9028
Mailing Address - Fax:818-386-9029
Practice Address - Street 1:13400 RIVERSIDE DR
Practice Address - Street 2:STE 310
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2544
Practice Address - Country:US
Practice Address - Phone:818-386-9028
Practice Address - Fax:818-386-9029
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12093103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY120930Medicaid