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General NPI Number Information
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NPI Number | 1184122269
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Entity Type | Individual
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Provider Name | MATTHEW KELSEY PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 04/19/2019
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Provider Practice Location Address
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Address Line | 521 E 86TH AVE STE H
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City | MERRILLVILLE
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State | IN
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Zip | 46410
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Country | US
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Telephone | 860-670-1373
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Fax |
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Provider Business Mailing Address
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Address Line | 216 WESTWIND DR APT A
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-7877
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Country | US
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Telephone |
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071009951
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License Number State | IL
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