Provider Demographics
NPI:1881074144
Name:MATTALINE, RACHEL (CSW)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:MATTALINE
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:230 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2026
Practice Address - Country:US
Practice Address - Phone:502-629-8990
Practice Address - Fax:502-394-3604
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2529561041C0700X
KY70351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047356Medicaid
KYK257342OtherKY MEDICARE
KY7100502820Medicaid