1245491604 NPI number — TERESA LYNN MATHIS LCSW

Table of content: TERESA LYNN MATHIS LCSW (NPI 1245491604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245491604 NPI number — TERESA LYNN MATHIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHIS
Provider First Name:
TERESA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245491604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3895 ROUTE 516
Provider Second Line Business Mailing Address:
SUITE 2B
Provider Business Mailing Address City Name:
OLD BRIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08857-2499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-679-4500
Provider Business Mailing Address Fax Number:
732-679-4549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3895 ROUTE 516
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
OLD BRIDGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08857-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-679-4500
Provider Business Practice Location Address Fax Number:
732-679-4549
Provider Enumeration Date:
06/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  44SC05234100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)