Healthcare Provider Details

I. General information

NPI: 1952668683
Provider Name (Legal Business Name): KELLY JAVIN DON MATHER MS, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 9TH AVE S STE B1
NAMPA ID
83651-3852
US

IV. Provider business mailing address

104 9TH AVE S STE B1
NAMPA ID
83651-3852
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-5806
  • Fax: 208-606-3680
Mailing address:
  • Phone: 208-495-5806
  • Fax: 208-606-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6836
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: