Provider Demographics
NPI:1477859155
Name:MATTINGLY, BARRETT ALEXANDER (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BARRETT
Middle Name:ALEXANDER
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2529
Mailing Address - Country:US
Mailing Address - Phone:502-349-6961
Mailing Address - Fax:502-348-1789
Practice Address - Street 1:875 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2529
Practice Address - Country:US
Practice Address - Phone:502-349-6961
Practice Address - Fax:502-348-1789
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist