Provider Demographics
NPI:1235714239
Name:MATHIS, DEJA A
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:A
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3914
Mailing Address - Country:US
Mailing Address - Phone:601-214-9609
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3914
Practice Address - Country:US
Practice Address - Phone:601-214-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician