Provider Demographics
NPI:1790159002
Name:MATTINGLY-MILLER, TRACY LEE (LPCC,NCC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:MATTINGLY-MILLER
Suffix:
Gender:F
Credentials:LPCC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BOGGS RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-7204
Mailing Address - Country:US
Mailing Address - Phone:606-657-6579
Mailing Address - Fax:
Practice Address - Street 1:1421 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1059
Practice Address - Country:US
Practice Address - Phone:859-624-2454
Practice Address - Fax:859-624-2454
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1205101YP2500X
KY105746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000991124OtherANTHEM PIN