Healthcare Provider Details

I. General information

NPI: 1467068924
Provider Name (Legal Business Name): ANTOINETTE MARIE MATHIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 5TH AVE S STE 301
LA CROSSE WI
54601-4098
US

IV. Provider business mailing address

124 GRAYSIDE AVE
MAUSTON WI
53948-1913
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0827
  • Fax:
Mailing address:
  • Phone: 608-847-7575
  • Fax: 608-847-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10811-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: