Provider Demographics
NPI:1215296868
Name:MATTINGLY, DEBRA L (MA, SLP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 NW FLAGLER AVE
Mailing Address - Street 2:#306
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-1160
Mailing Address - Country:US
Mailing Address - Phone:517-927-0050
Mailing Address - Fax:
Practice Address - Street 1:275 NW FLAGLER AVE
Practice Address - Street 2:#306
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1160
Practice Address - Country:US
Practice Address - Phone:517-927-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2234715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist