Provider Demographics
NPI:1073048112
Name:MATTINGLY, ADRIANA (LISW-CP)
Entity Type:Individual
Prefix:
First Name:ADRIANA
Middle Name:
Last Name:MATTINGLY
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 1:171 CHURCH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-3137
Mailing Address - Country:US
Mailing Address - Phone:843-823-6811
Mailing Address - Fax:843-823-6811
Practice Address - Street 1:171 CHURCH ST STE 230
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-3137
Practice Address - Country:US
Practice Address - Phone:843-823-6811
Practice Address - Fax:843-823-6811
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC119391041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid