Healthcare Provider Details

I. General information

NPI: 1316338866
Provider Name (Legal Business Name): KELLY DALLAIRE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY MATZKE LPC

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S ADAMS ST STE 205
GREEN BAY WI
54301-4117
US

IV. Provider business mailing address

615 REID ST
DE PERE WI
54115-1346
US

V. Phone/Fax

Practice location:
  • Phone: 920-737-7695
  • Fax:
Mailing address:
  • Phone: 920-737-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7682-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: