Provider Demographics
NPI:1679693006
Name:MATHIS, MARY SUSAN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:WITTKAMPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:1261B CHERAW RD
Mailing Address - Street 2:
Mailing Address - City:CASSATT
Mailing Address - State:SC
Mailing Address - Zip Code:29032-9407
Mailing Address - Country:US
Mailing Address - Phone:803-397-1990
Mailing Address - Fax:
Practice Address - Street 1:1261B CHERAW RD
Practice Address - Street 2:
Practice Address - City:CASSATT
Practice Address - State:SC
Practice Address - Zip Code:29032
Practice Address - Country:US
Practice Address - Phone:803-397-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5298101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health