Provider Demographics
NPI:1558795807
Name:MATHIS, KRISTOPHER IAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:IAN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 WESTWOOD PLZ
Mailing Address - Street 2:SUITE 2437
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1556
Mailing Address - Country:US
Mailing Address - Phone:310-384-0374
Mailing Address - Fax:
Practice Address - Street 1:221 WESTWOOD PLZ
Practice Address - Street 2:SUITE 2437
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1556
Practice Address - Country:US
Practice Address - Phone:310-384-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25704103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist