Provider Demographics
NPI:1003580069
Name:MATHIS, CHASMA
Entity type:Individual
Prefix:
First Name:CHASMA
Middle Name:
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 1:1130 HIGH MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-1218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1130 HIGH MEADOW DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-1218
Practice Address - Country:US
Practice Address - Phone:443-600-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2023-01-19
Deactivation Date:2021-10-07
Deactivation Code:
Reactivation Date:2023-01-19
Provider Licenses
StateLicense IDTaxonomies
FLPY10256103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical