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General NPI Number Information
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NPI Number | 1609253681
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Entity Type | Individual
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Provider Name | MARISHA LARAE MATHIS LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/29/2015
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Last Update Date | 11/01/2018
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Provider Practice Location Address
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Address Line | 4000 WAKE FOREST RD STE 200
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City | RALEIGH
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State | NC
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Zip | 27609-6859
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Country | US
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Telephone | 919-865-8710
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Fax |
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Provider Business Mailing Address
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Address Line | 5010 GARRETT RD APT 534
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City | DURHAM
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State | NC
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Zip | 27707-5950
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Country | US
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Telephone | 919-824-6016
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C009792
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License Number State | NC
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