Healthcare Provider Details

I. General information

NPI: 1518648476
Provider Name (Legal Business Name): DIANA MATHIS LCSW-26440
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA MATHIS, LCSW LCSW-26440

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26734 JORDAN RD
HELENDALE CA
92342-7878
US

IV. Provider business mailing address

P O BOX 840-180
HELENDALE CA
92342-7878
US

V. Phone/Fax

Practice location:
  • Phone: 760-232-6706
  • Fax:
Mailing address:
  • Phone: 760-232-6706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26440
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: