MEDICARE: MARY B MATTIS LCSW, LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	53118	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	12038	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12020270	OTHER	TX	CAHQ
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548481195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY B MATTIS LCSW, LCDC

Provider Business Mailing Address
First Line	:	2312 WESTERN TRAILS BLVD
Second Line	:	BUILDING D, SUITE 404
City	:	AUSTIN
State	:	TX
Zip	:	78745-1642
Country	:	US
Telephone Number	:	512-701-7378
Fax Number	:

Provider Business Practice Location Address
First Line	:	2312 WESTERN TRAILS BLVD
Second Line	:	BUILDING D, SUITE 404
City	:	AUSTIN
State	:	TX
Zip	:	78745-1642
Country	:	US
Telephone Number	:	512-701-7378
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	03/30/2013

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