Basic Information
| Provider Information | |||||||||
| NPI: | 1750785473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | EVETTE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 S 6TH AVE | ||||||||
| Address2: | MAIL STOP 4-1168A | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3601 S 6TH AVE | ||||||||
| Address2: | BLD 90, ROOM 1132 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 01/28/2015 | ||||||||
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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 | LMSW-13950 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LMSW 13950 | AZ | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.