Provider Demographics
NPI:1790826790
Name:MATHIS, KATHRYN GRIM (LCAS, CSI)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:GRIM
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LCAS, CSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 WATERSIDE DR
Mailing Address - Street 2:APT 302
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9739
Mailing Address - Country:US
Mailing Address - Phone:910-386-8598
Mailing Address - Fax:
Practice Address - Street 1:305 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4425
Practice Address - Country:US
Practice Address - Phone:252-335-9400
Practice Address - Fax:252-335-9404
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111930Medicaid