Provider Demographics
NPI:1952890600
Name:MATTINGLY, JULIE (BCBA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 GISLER AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2228
Mailing Address - Country:US
Mailing Address - Phone:949-325-5686
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE STE 125
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7701
Practice Address - Country:US
Practice Address - Phone:909-689-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-29408103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-29408OtherBOARD CERTIFICATION