Provider Demographics
NPI:1144464207
Name:MATTINGLY, ELLEN FOSTER (SLPD, CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:FOSTER
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:SLPD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 S JOG RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33415-6093
Mailing Address - Country:US
Mailing Address - Phone:561-641-5757
Mailing Address - Fax:561-641-7373
Practice Address - Street 1:2168 JOG ROAD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415
Practice Address - Country:US
Practice Address - Phone:561-641-5757
Practice Address - Fax:561-641-7373
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109652000Medicaid