Provider Demographics
NPI:1699528208
Name:MATTOS, KELLY MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MATTOS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9869 PULASKI PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:TONEY
Mailing Address - State:AL
Mailing Address - Zip Code:35773-7201
Mailing Address - Country:US
Mailing Address - Phone:256-850-4091
Mailing Address - Fax:256-970-1643
Practice Address - Street 1:9869 PULASKI PIKE STE C
Practice Address - Street 2:
Practice Address - City:TONEY
Practice Address - State:AL
Practice Address - Zip Code:35773-7201
Practice Address - Country:US
Practice Address - Phone:256-850-4091
Practice Address - Fax:256-970-1643
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6452G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker