Provider Demographics
NPI:1609253681
Name:MATHIS, MARISHA LARAE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARISHA
Middle Name:LARAE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 GARRETT RD
Mailing Address - Street 2:APT 534
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5950
Mailing Address - Country:US
Mailing Address - Phone:919-824-6016
Mailing Address - Fax:
Practice Address - Street 1:4000 WAKE FOREST RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6859
Practice Address - Country:US
Practice Address - Phone:919-865-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0097921041C0700X
NCP005954101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health