Basic Information
| Provider Information | |||||||||
| NPI: | 1558918847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5503 105TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794248270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067731179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 7TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CHILDRESS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 792012627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883656271 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2019 | ||||||||
| LastUpdateDate: | 12/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/14/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 54350 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 54350 | 01 | TX | LICENSE | OTHER |