Healthcare Provider Details

I. General information

NPI: 1063127389
Provider Name (Legal Business Name): MELISSA ANNE MATHIS PLMHP, PLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 S 48TH ST STE 1
LINCOLN NE
68516-1287
US

IV. Provider business mailing address

3139 COLT AVE
LINCOLN NE
68507-1109
US

V. Phone/Fax

Practice location:
  • Phone: 402-991-8093
  • Fax:
Mailing address:
  • Phone: 402-805-7048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13281
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7818
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: