Doctor Name: | MATTHEW KELLY |
NPI Number: | 1033588678 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 335 W 1st St Oswego, NY - 131263689 |
Business Phone Number: | 3153433344 |
Business Fax Number: | |
Mailing Address: | 335 W 1st St, OSWEGO |
State: | NY |
Postal Code: | 131263689 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 09/24/2015 |
NPI Last Update Date: | 09/24/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |