Provider Demographics
NPI:1265088710
Name:MATHIS, CORA LEE (MSW)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:LEE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 TIMBER TRACE LN APT 104
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-1925
Mailing Address - Country:US
Mailing Address - Phone:786-315-1078
Mailing Address - Fax:
Practice Address - Street 1:7550 FUTURES DR STE 11
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9095
Practice Address - Country:US
Practice Address - Phone:407-730-7983
Practice Address - Fax:844-743-6224
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health