Provider Demographics
NPI:1750836672
Name:MATHIEU, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MATHIEU
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 1:10917 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-2832
Mailing Address - Country:US
Mailing Address - Phone:361-945-3425
Mailing Address - Fax:
Practice Address - Street 1:10917 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2832
Practice Address - Country:US
Practice Address - Phone:361-945-3425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX611334171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator