Provider Demographics
NPI:1982379434
Name:MATTARELLA, KAILEY BROOKE
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:BROOKE
Last Name:MATTARELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 E 7TH ST APT 22
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5715
Mailing Address - Country:US
Mailing Address - Phone:231-631-6085
Mailing Address - Fax:
Practice Address - Street 1:100 PINE ST STE 140
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2603
Practice Address - Country:US
Practice Address - Phone:616-748-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851110521104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker