Provider Demographics
NPI:1710206487
Name:MATHIS, PHYLLIS RENA
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:RENA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 NE 23RD DR
Mailing Address - Street 2:APT. 4
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1277
Mailing Address - Country:US
Mailing Address - Phone:954-513-7275
Mailing Address - Fax:
Practice Address - Street 1:2881 E OAKLAND PARK BLVD
Practice Address - Street 2:STE.317
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1813
Practice Address - Country:US
Practice Address - Phone:954-315-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker