Provider Demographics
NPI:1124704663
Name:KELLY, MATTHEW (MFT-I, CPC-I, LCADCI)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MFT-I, CPC-I, LCADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 CRESTDALE LN APT 64
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-1007
Mailing Address - Country:US
Mailing Address - Phone:979-251-0014
Mailing Address - Fax:
Practice Address - Street 1:4011 MCLEOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4305
Practice Address - Country:US
Practice Address - Phone:979-251-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5251101YP2500X
NVMI4215101YM0800X
NV07347-LCI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)