Provider Demographics
NPI:1568709053
Name:MATHIS, MAXINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAXINE
Middle Name:
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 1:250 W 131ST ST APT 11D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-2049
Mailing Address - Country:US
Mailing Address - Phone:347-463-6872
Mailing Address - Fax:
Practice Address - Street 1:250 W 131ST ST APT 11D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-2049
Practice Address - Country:US
Practice Address - Phone:347-463-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23391101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health