Provider Demographics
NPI:1154675031
Name:MATTINGLY, REBECCA D (LPC, LCAS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WAKE FOREST RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6859
Mailing Address - Country:US
Mailing Address - Phone:919-865-8710
Mailing Address - Fax:
Practice Address - Street 1:4000 WAKE FOREST RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6859
Practice Address - Country:US
Practice Address - Phone:919-865-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-3256101YA0400X
NC10421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)