Provider Demographics
NPI:1982177762
Name:MATTINGLY, LORI MICHELLE (AMFT 106316)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MICHELLE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:AMFT 106316
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:MATTINGLY
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT 106316
Mailing Address - Street 1:3545 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3941
Mailing Address - Country:US
Mailing Address - Phone:562-490-7600
Mailing Address - Fax:
Practice Address - Street 1:3545 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3941
Practice Address - Country:US
Practice Address - Phone:562-490-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106316106H00000X
CA139097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist