Provider Demographics
NPI:1316391782
Name:MATTINGLY, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MATTINGLY
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 1:1809 FOORS LN
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 TAMARACK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6984
Practice Address - Country:US
Practice Address - Phone:270-926-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist