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General NPI Number Information
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NPI Number | 1710206487
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Entity Type | Individual
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Provider Name | MS. PHYLLIS RENA MATHIS
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Gender | Female
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Dates
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Enumeration Date | 05/20/2010
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Last Update Date | 06/27/2011
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Provider Practice Location Address
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Address Line | 2881 E OAKLAND PARK BLVD STE.317
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-1813
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Country | US
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Telephone | 954-315-1752
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Fax |
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Provider Business Mailing Address
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Address Line | 809 NE 23RD DR APT. 4
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City | WILTON MANORS
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State | FL
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Zip | 33305-1277
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Country | US
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Telephone | 954-513-7275
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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Taxonomy #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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