Provider Demographics
NPI:1013235548
Name:MATTINGLY, GOBEL E (MS, PTA, ATC)
Entity Type:Individual
Prefix:
First Name:GOBEL
Middle Name:E
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:MS, PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-599-2515
Mailing Address - Fax:
Practice Address - Street 1:943 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2812
Practice Address - Country:US
Practice Address - Phone:304-599-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA 001823225200000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPTA 001823OtherPHYSICAL THERAPIST ASSISTANT
070702738OtherBOC CERTIFICATION