Provider Demographics
NPI:1689418394
Name:MATHIS, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:6872 HEFFNER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-8414
Mailing Address - Country:US
Mailing Address - Phone:213-375-8792
Mailing Address - Fax:
Practice Address - Street 1:7235 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6724
Practice Address - Country:US
Practice Address - Phone:213-584-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16070171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator