Provider Demographics
NPI:1215902762
Name:MATELJAN, KELLY MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:MATELJAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GALLITZIN
Mailing Address - State:PA
Mailing Address - Zip Code:16641-1427
Mailing Address - Country:US
Mailing Address - Phone:814-534-0745
Mailing Address - Fax:
Practice Address - Street 1:131 MARKET ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1628
Practice Address - Country:US
Practice Address - Phone:814-534-0745
Practice Address - Fax:814-536-5431
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0151701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1215902762OtherNPIN
PAMA 1446205OtherBC/ BS NETWORK PROVIDER #
PA1215902762Medicare UPIN