Healthcare Provider Details

I. General information

NPI: 1124258918
Provider Name (Legal Business Name): MATTHEW BRIAN KELLEY M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 ACADEMY RD NE
ALBUQUERQUE NM
87111-1107
US

IV. Provider business mailing address

8600 ACADEMY RD NE
ALBUQUERQUE NM
87111-1107
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-3628
  • Fax: 505-856-7103
Mailing address:
  • Phone: 505-821-3628
  • Fax: 505-856-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0124261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: