Provider Demographics
NPI:1053112847
Name:NELSON MATTINGLY, SELENA MARIE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:MARIE
Last Name:NELSON MATTINGLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10611 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MACKVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40040-7047
Mailing Address - Country:US
Mailing Address - Phone:270-222-9777
Mailing Address - Fax:
Practice Address - Street 1:125 REARDON BLVD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2034
Practice Address - Country:US
Practice Address - Phone:877-498-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician