Basic Information
| Provider Information | |||||||||
| NPI: | 1992930143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 W MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093255502 | ||||||||
| FaxNumber: | 5093259839 | ||||||||
| Practice Location | |||||||||
| Address1: | 1803 W MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093255502 | ||||||||
| FaxNumber: | 5093259839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | RC60020419 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.