Healthcare Provider Details

I. General information

NPI: 1265237267
Provider Name (Legal Business Name): KELLI MATAJCICH P-LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 SULLIVAN AVE
FARMINGTON NM
87401-4324
US

IV. Provider business mailing address

2110 SULLIVAN AVE
FARMINGTON NM
87401-4324
US

V. Phone/Fax

Practice location:
  • Phone: 505-578-7563
  • Fax:
Mailing address:
  • Phone: 505-578-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2025-0466
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: