Provider Demographics
NPI:1316138134
Name:MATTINGLY-MARDIS, MELISSA (OTR/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MATTINGLY-MARDIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9726
Mailing Address - Country:US
Mailing Address - Phone:270-692-8826
Mailing Address - Fax:270-789-6531
Practice Address - Street 1:991 MARTIN RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9726
Practice Address - Country:US
Practice Address - Phone:270-692-8826
Practice Address - Fax:270-789-6531
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2253225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01924OtherFIRST STEPS