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General NPI Number Information
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NPI Number | 1780399725
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Entity Type | Organization
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Legal Business Name | HEALING GROVE PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 01/13/2023
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Last Update Date | 02/24/2023
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Provider Practice Location Address
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Address Line | 112 SHADY TREE LN
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City | FAIRMONT
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State | WV
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Zip | 26554-8394
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Country | US
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Telephone | 681-404-0129
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 113
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City | KINGMONT
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State | WV
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Zip | 26578-0113
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Country | US
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Telephone | 681-404-0129
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Fax |
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Authorized Official
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Title or Position | FOUNDER/PSYCHOLOGIST
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Name | DR. MATTHEW CRAIG KELLAR
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Credential | PSYD
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Telephone | 681-404-0129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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