Healthcare Provider Details

I. General information

NPI: 1538169743
Provider Name (Legal Business Name): DAVID C MATHIS EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HOGAN ST
TULLAHOMA TN
37388-3338
US

IV. Provider business mailing address

204 W HOGAN ST
TULLAHOMA TN
37388-3338
US

V. Phone/Fax

Practice location:
  • Phone: 931-393-1043
  • Fax: 931-393-1000
Mailing address:
  • Phone: 931-393-1043
  • Fax: 931-393-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP1711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: