Healthcare Provider Details

I. General information

NPI: 1790159002
Provider Name (Legal Business Name): TRACY LEE MATTINGLY-MILLER LPCC,NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LEXINGTON RD
RICHMOND KY
40475-1059
US

IV. Provider business mailing address

345 BOGGS RD
LONDON KY
40744-7204
US

V. Phone/Fax

Practice location:
  • Phone: 859-624-2454
  • Fax: 859-624-2454
Mailing address:
  • Phone: 606-657-6579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1205
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number105746
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: