Provider Demographics
NPI:1881747061
Name:MATHISEN, DONNA M (MS, RPT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:MATHISEN
Suffix:
Gender:F
Credentials:MS, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 S EAST AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2344
Mailing Address - Country:US
Mailing Address - Phone:941-362-2000
Mailing Address - Fax:941-362-9114
Practice Address - Street 1:1217 S EAST AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2344
Practice Address - Country:US
Practice Address - Phone:941-362-2000
Practice Address - Fax:941-362-9114
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0012183174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT0012183OtherWORKERS COMPENSATION
FLY6975OtherBLUE CROSS BLUE SHIELD
FLY6975OtherBLUE CROSS BLUE SHIELD
FLS45460Medicare UPIN