Basic Information
| Provider Information | |||||||||
| NPI: | 1639408990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3907 ELGIN WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402164908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027782006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 517 LITTLE LEAGUE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471296629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2009 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1048 | KY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 34005676A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 3320 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.