Healthcare Provider Details

I. General information

NPI: 1093581555
Provider Name (Legal Business Name): EMMA MARIE MATTINGLY LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ELLINGTON BLVD # 509
GAITHERSBURG MD
20878-4591
US

IV. Provider business mailing address

325 ELLINGTON BLVD # 509
GAITHERSBURG MD
20878-4591
US

V. Phone/Fax

Practice location:
  • Phone: 703-291-3736
  • Fax:
Mailing address:
  • Phone: 703-291-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLGP14588
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: