Provider Demographics
NPI:1790141059
Name:MATTINGLY, ANDREA (CSPRN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:CSPRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:2210 TUCKER STATION RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4525
Practice Address - Country:US
Practice Address - Phone:502-366-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-02
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)