Healthcare Provider Details

I. General information

NPI: 1114249646
Provider Name (Legal Business Name): MATTHEW TODD KELLY M.A. CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 5TH ST
SANTA FE NM
87505-5402
US

IV. Provider business mailing address

3 PRAIRIE CREST DR
SANTA FE NM
87508-1314
US

V. Phone/Fax

Practice location:
  • Phone: 505-204-8919
  • Fax:
Mailing address:
  • Phone: 505-204-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberC-4614
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: