Provider Demographics
NPI:1629109954
Name:MATAXIS, THEODORE CHRISTOPHER III (MA, LPA)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:CHRISTOPHER
Last Name:MATAXIS
Suffix:III
Gender:M
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 FUR CT E
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8210
Mailing Address - Country:US
Mailing Address - Phone:910-585-1399
Mailing Address - Fax:
Practice Address - Street 1:318 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371-3018
Practice Address - Country:US
Practice Address - Phone:910-576-1188
Practice Address - Fax:910-576-1182
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2540103T00000X, 103TB0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities