Provider Demographics
NPI:1902143803
Name:MATHIS, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:UT
Mailing Address - Zip Code:84340-9738
Mailing Address - Country:US
Mailing Address - Phone:801-781-0959
Mailing Address - Fax:
Practice Address - Street 1:189 S STATE ST STE 230
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1001
Practice Address - Country:US
Practice Address - Phone:801-781-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
UT6722056-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical