Provider Demographics
NPI:1790390896
Name:MATTHEWS, KELLI R
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:R
Last Name:MATTHEWS
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 1:5577 VINCENT GATE TER UNIT 1220
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-2578
Mailing Address - Country:US
Mailing Address - Phone:832-477-7586
Mailing Address - Fax:
Practice Address - Street 1:3814 12TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2630
Practice Address - Country:US
Practice Address - Phone:202-656-9059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician