Provider Demographics
NPI:1578280525
Name:MATHIS, LAURELLE MARIE
Entity Type:Individual
Prefix:
First Name:LAURELLE
Middle Name:MARIE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18513 KIMBROUGH ST
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-2928
Mailing Address - Country:US
Mailing Address - Phone:661-312-6139
Mailing Address - Fax:
Practice Address - Street 1:28200 BOUQUET CANYON RD STE G
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:CA
Practice Address - Zip Code:91350-1447
Practice Address - Country:US
Practice Address - Phone:661-312-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASR00679002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty