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General NPI Number Information
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NPI Number | 1124704663
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Entity Type | Individual
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Provider Name | MATTHEW KELLY MFT-I, CPC-I, LCADCI
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Gender | Male
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Dates
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Enumeration Date | 06/27/2023
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 4011 MCLEOD DR
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City | LAS VEGAS
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State | NV
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Zip | 89121-4305
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Country | US
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Telephone | 979-251-0014
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Fax |
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Provider Business Mailing Address
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Address Line | 451 CRESTDALE LN APT 64
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City | LAS VEGAS
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State | NV
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Zip | 89144-1007
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Country | US
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Telephone | 979-251-0014
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | CI5251
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MI4215
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 07347-LCI
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License Number State | NV
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