Provider Demographics
NPI:1760901219
Name:MATHIS, TRACIE VINETTE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:VINETTE
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 1:13524 ULYSSES S GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-3941
Mailing Address - Country:US
Mailing Address - Phone:512-542-4543
Mailing Address - Fax:
Practice Address - Street 1:13524 ULYSSES S GRANT ST
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-3941
Practice Address - Country:US
Practice Address - Phone:512-542-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor