Provider Demographics
NPI:1912553702
Name:MATTINGLEY, KIMBERLEE ILISE (BA, SUDCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:ILISE
Last Name:MATTINGLEY
Suffix:
Gender:F
Credentials:BA, SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 DUROCK RD STE 205
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8568
Mailing Address - Country:US
Mailing Address - Phone:530-621-4687
Mailing Address - Fax:
Practice Address - Street 1:3974 DUROCK RD STE 205
Practice Address - Street 2:
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8568
Practice Address - Country:US
Practice Address - Phone:530-621-4687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10848101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)