Provider Demographics
NPI:1114249646
Name:KELLY, MATTHEW TODD (MA CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TODD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PRAIRIE CREST DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1314
Mailing Address - Country:US
Mailing Address - Phone:505-204-8919
Mailing Address - Fax:
Practice Address - Street 1:1919 5TH ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5402
Practice Address - Country:US
Practice Address - Phone:505-204-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-4614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist