Provider Demographics
NPI:1972929487
Name:MATTINGLY, BRIAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 GREAT PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-2033
Mailing Address - Country:US
Mailing Address - Phone:757-871-7773
Mailing Address - Fax:
Practice Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7159
Practice Address - Country:US
Practice Address - Phone:336-515-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005599103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical