Provider Demographics
NPI:1437687589
Name:KELLEY, MATTHEW DEAN (LSCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-2101
Mailing Address - Country:US
Mailing Address - Phone:316-288-3504
Mailing Address - Fax:
Practice Address - Street 1:106 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-2101
Practice Address - Country:US
Practice Address - Phone:316-288-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
KS056621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker