Provider Demographics
NPI:1134551518
Name:MATTINGLY, JOE (ATC)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 MILLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-5131
Mailing Address - Country:US
Mailing Address - Phone:630-464-5778
Mailing Address - Fax:
Practice Address - Street 1:2615 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-2450
Practice Address - Country:US
Practice Address - Phone:708-493-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0035622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer