Provider Demographics
NPI:1952630865
Name:MATHIS, LAJENE TONIECE
Entity Type:Individual
Prefix:
First Name:LAJENE
Middle Name:TONIECE
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 1:6220 LAKE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-0502
Mailing Address - Country:US
Mailing Address - Phone:912-484-4219
Mailing Address - Fax:
Practice Address - Street 1:4301 N FEDERAL HWY
Practice Address - Street 2:SUITE 2 SOUTH
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-6519
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist