Healthcare Provider Details

I. General information

NPI: 1992193387
Provider Name (Legal Business Name): DEBORAH M. MATHIS LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MERCHANT ST
AUDUBON NJ
08106-1424
US

IV. Provider business mailing address

108 W MERCHANT ST
AUDUBON NJ
08106-1424
US

V. Phone/Fax

Practice location:
  • Phone: 609-501-5910
  • Fax: 856-546-1480
Mailing address:
  • Phone: 609-501-5910
  • Fax: 310-348-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05730300
License Number StateNJ

VIII. Authorized Official

Name: DEBORAH M MATHIS
Title or Position: PRESIDENT
Credential: MSW, CSSW, LCSW
Phone: 609-501-5910