Provider Demographics
NPI:1659793198
Name:MATTHEWS, KELLY JEAN (MED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:ULRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 W SWANSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-357-0890
Mailing Address - Fax:907-357-0891
Practice Address - Street 1:33880 COMMUNITY COLLEGE DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-262-0893
Practice Address - Fax:907-262-0891
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-14109103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst