Provider Demographics
NPI:1154783181
Name:MATTINGLY, CORINNE (LPCA)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 GLENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-9033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 GLENSBORO RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-9033
Practice Address - Country:US
Practice Address - Phone:502-839-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00225102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid