Provider Demographics
NPI:1447368485
Name:MATTIX, GAIL (LISW-CP)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:MATTIX
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RIVER BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5662
Mailing Address - Country:US
Mailing Address - Phone:843-814-9707
Mailing Address - Fax:
Practice Address - Street 1:103 RIVER BREEZE DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5662
Practice Address - Country:US
Practice Address - Phone:843-814-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4770104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ352488934Medicare UPIN
SC8934Medicare PIN