Provider Demographics
NPI:1356673024
Name:MATTINGLY, COURTNEY H (MSOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:H
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 FENLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 FENLEY AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2741
Practice Address - Country:US
Practice Address - Phone:502-905-5989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4179225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist