Healthcare Provider Details

I. General information

NPI: 1598036675
Provider Name (Legal Business Name): MATILDA MATHIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 LAKE MONROE PL
SAINT AUGUSTINE FL
32092-2495
US

IV. Provider business mailing address

429 LAKE MONROE PL
SAINT AUGUSTINE FL
32092-2495
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-9841
  • Fax:
Mailing address:
  • Phone: 904-940-9841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: