Provider Demographics
NPI:1053040048
Name:MATTINGLY-CLOER, KIMBERLY RUTH
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RUTH
Last Name:MATTINGLY-CLOER
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 1:456 SEVEN SPRINGS LOOP
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9137
Mailing Address - Country:US
Mailing Address - Phone:704-929-6117
Mailing Address - Fax:
Practice Address - Street 1:1812 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3524
Practice Address - Country:US
Practice Address - Phone:704-450-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC014138101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
01OtherPRIVATE PAY