Healthcare Provider Details

I. General information

NPI: 1619411311
Provider Name (Legal Business Name): EMILY MATHIS ED. M, MA, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 CONSTITUTION AVE NE SUITE 4
ALBUQUERQUE NM
87110-5900
US

IV. Provider business mailing address

6020 CONSTITUTION AVE NE SUITE 4
ALBUQUERQUE NM
87110-5900
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax: 505-255-4206
Mailing address:
  • Phone: 505-255-5099
  • Fax: 505-255-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number361587
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: