1033653761 NPI number — KATIE MATTINGLEY MS, CCC-SLP

Table of content: KATIE MATTINGLEY MS, CCC-SLP (NPI 1033653761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033653761 NPI number — KATIE MATTINGLEY MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTINGLEY
Provider First Name:
KATIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033653761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 404
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITEFISH
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59937-0404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-859-8903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 2ND ST E
Provider Second Line Business Practice Location Address:
SUITE 322
Provider Business Practice Location Address City Name:
WHITEFISH
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59937-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-730-3454
Provider Business Practice Location Address Fax Number:
855-312-7680
Provider Enumeration Date:
12/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP-SP-LC-1221 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033653761 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com