Provider Demographics
NPI:1013153006
Name:MATHIS, LARRYMI DANIELLE
Entity Type:Individual
Prefix:MS
First Name:LARRYMI
Middle Name:DANIELLE
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 1:3455 HIGHLAND RD # 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-7193
Mailing Address - Country:US
Mailing Address - Phone:469-735-3395
Mailing Address - Fax:469-941-4158
Practice Address - Street 1:3455 HIGHLAND RD # 101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-7193
Practice Address - Country:US
Practice Address - Phone:469-735-3395
Practice Address - Fax:469-941-4158
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness