Provider Demographics
NPI:1386718567
Name:MATTINGLY, CHRISTINE ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ANN
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13733-2211
Mailing Address - Country:US
Mailing Address - Phone:607-336-1380
Mailing Address - Fax:
Practice Address - Street 1:105 LEILANIS LN
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-3540
Practice Address - Country:US
Practice Address - Phone:607-337-1680
Practice Address - Fax:607-336-1380
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050209-1101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY38743TMedicare ID - Type Unspecified