Provider Demographics
NPI:1093581555
Name:MATTINGLY, EMMA MARIE (LGPC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:MARIE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 ELLINGTON BLVD # 509
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4591
Mailing Address - Country:US
Mailing Address - Phone:703-291-3736
Mailing Address - Fax:
Practice Address - Street 1:521 ARBOR DR UNIT 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7432
Practice Address - Country:US
Practice Address - Phone:703-291-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14588103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling