Provider Demographics
NPI:1326169913
Name:MATTINGLY, CAROL A (SLP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 WHITEHALL CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3026
Mailing Address - Country:US
Mailing Address - Phone:540-774-4278
Mailing Address - Fax:
Practice Address - Street 1:GENESIS REHAB
Practice Address - Street 2:2001 RIDGEWOOD DRIVE
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-378-4120
Practice Address - Fax:540-378-4121
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist