Provider Demographics
NPI:1619699816
Name:MATHIS, MACEY (SLP)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 W 58TH ST UNIT 6
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-6516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 N POPLAR AVE
Practice Address - Street 2:
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2152
Practice Address - Country:US
Practice Address - Phone:605-498-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1058-PROV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist