Healthcare Provider Details

I. General information

NPI: 1740798818
Provider Name (Legal Business Name): CHARLENA MATHIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 DISSTON ST
PHILADELPHIA PA
19111-4504
US

IV. Provider business mailing address

1500 S DOUGLAS RD STE 230
CORAL GABLES FL
33134-4108
US

V. Phone/Fax

Practice location:
  • Phone: 215-801-5530
  • Fax: 215-801-5530
Mailing address:
  • Phone: 844-854-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberLABA429
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: