Basic Information
Provider Information
NPI: 1003001074
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MATTIS
FirstName: DALIA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: ED D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5450 NW CENTRAL DR STE 109
Address2:  
City: HOUSTON
State: TX
PostalCode: 770922024
CountryCode: US
TelephoneNumber: 7138950062
FaxNumber: 7138950062
Practice Location
Address1: 5450 NW CENTRAL DR STE 109
Address2:  
City: HOUSTON
State: TX
PostalCode: 770922024
CountryCode: US
TelephoneNumber: 7138950062
FaxNumber: 7138950062
Other Information
ProviderEnumerationDate: 09/12/2007
LastUpdateDate: 09/12/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X17843TXY Behavioral Health & Social Service ProvidersCounselor 

ID Information
IDTypeStateIssuerDescription
16572560105TX MEDICAID


Home