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General NPI Number Information
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NPI Number | 1972929487
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Entity Type | Individual
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Provider Name | BRIAN MATTINGLY PSYD
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Gender | Male
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Dates
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Enumeration Date | 03/07/2014
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Last Update Date | 01/11/2017
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Provider Practice Location Address
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Address Line | 1695 KERNERSVILLE MEDICAL PKWY
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City | KERNERSVILLE
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State | NC
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Zip | 27284-7159
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Country | US
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Telephone | 336-515-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 513 GREAT PARK DR
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City | NEWPORT NEWS
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State | VA
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Zip | 23608-2033
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Country | US
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Telephone | 757-871-7773
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810005599
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License Number State | VA
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