Provider Demographics
NPI:1346401593
Name:MATTINGLY, LEE MEGAN (MA)
Entity Type:Individual
Prefix:MRS
First Name:LEE
Middle Name:MEGAN
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N DIXIE AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2621
Mailing Address - Country:US
Mailing Address - Phone:270-692-1304
Mailing Address - Fax:270-234-8028
Practice Address - Street 1:1311 N DIXIE AVE BLDG C
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-692-1304
Practice Address - Fax:270-234-8028
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170692103TC0700X
0978103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid