1114249646 NPI number — MR. MATTHEW TODD KELLY M.A. CCC-SLP

Table of content: MR. MATTHEW TODD KELLY M.A. CCC-SLP (NPI 1114249646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114249646 NPI number — MR. MATTHEW TODD KELLY M.A. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MATTHEW
Provider Middle Name:
TODD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.A. CCC-SLP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114249646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PRAIRIE CREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87508-1314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-204-8919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-5402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-204-8919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  C-4614 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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