Provider Demographics
NPI:1629403316
Name:MATTINGLY, LISA ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MARSH OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-8709
Mailing Address - Country:US
Mailing Address - Phone:910-612-1816
Mailing Address - Fax:
Practice Address - Street 1:200 NORTHPOINTE CIR
Practice Address - Street 2:
Practice Address - City:SEVEN FIELDS
Practice Address - State:PA
Practice Address - Zip Code:16046-7861
Practice Address - Country:US
Practice Address - Phone:610-925-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8817224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant