MEDICARE: RHONDA MATTINGLY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	1168	KY

General Provider Information

NPI Number	:	1659777258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RHONDA MATTINGLY LLC

Provider Business Mailing Address
First Line	:	207 HILLCREST AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1535
Country	:	US
Telephone Number	:	502-552-4598
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 HILLCREST AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1535
Country	:	US
Telephone Number	:	502-552-4598
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	RHONDA MATTINGLY
Credential	:	EDD
Telephone Number	:	502-552-4598

Provider Enumeration Date	:	11/08/2014
Last Update Date	:	11/08/2014

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