Provider Demographics
NPI:1598283780
Name:MATHIS, TIANA SHINDELL
Entity Type:Individual
Prefix:MISS
First Name:TIANA
Middle Name:SHINDELL
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TIANA
Other - Middle Name:SHINDELL
Other - Last Name:OATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:456 BEACH 40TH ST APT 7F
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1356
Mailing Address - Country:US
Mailing Address - Phone:718-414-7548
Mailing Address - Fax:
Practice Address - Street 1:456 BEACH 40TH ST APT 7F
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1356
Practice Address - Country:US
Practice Address - Phone:718-414-7548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid