Provider Demographics
NPI:1215079637
Name:MATTINGLY, MAUREEN ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ANN
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:MAUREEN
Other - Middle Name:ANN
Other - Last Name:MATTINGLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SPEECH PATHOLOGIST
Mailing Address - Street 1:2791 COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-2835
Mailing Address - Country:US
Mailing Address - Phone:636-795-4153
Mailing Address - Fax:636-677-3984
Practice Address - Street 1:100 S GARRISON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2538
Practice Address - Country:US
Practice Address - Phone:314-340-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111331235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist