Provider Demographics
NPI:1033653761
Name:MATTINGLEY, KATIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MATTINGLEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-0404
Mailing Address - Country:US
Mailing Address - Phone:208-859-8903
Mailing Address - Fax:
Practice Address - Street 1:100 2ND ST E
Practice Address - Street 2:SUITE 322
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2410
Practice Address - Country:US
Practice Address - Phone:406-730-3454
Practice Address - Fax:855-312-7680
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LC-1221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1033653761Medicaid