Provider Demographics
NPI:1689240889
Name:MCMATH, KANELLE
Entity Type:Individual
Prefix:MS
First Name:KANELLE
Middle Name:
Last Name:MCMATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 FISHING POINT DR STE 202
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2585
Mailing Address - Country:US
Mailing Address - Phone:757-206-2850
Mailing Address - Fax:
Practice Address - Street 1:11835 FISHING POINT DR STE 202
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2585
Practice Address - Country:US
Practice Address - Phone:757-206-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician