Basic Information
| Provider Information | |||||||||
| NPI: | 1689869877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | BEATRICE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENKINS | ||||||||
| OtherFirstName: | BEATRICE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28 BRIAR LN | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060021321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602438668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 487 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060403982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604328775 | ||||||||
| FaxNumber: | 8604328581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 008072 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.