Provider Demographics
NPI:1790305423
Name:MATHIS, KIMBERLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:MCDONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:955 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7832
Mailing Address - Country:US
Mailing Address - Phone:941-441-5803
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician