Provider Demographics
NPI:1841429719
Name:MATTIS, KELLY L (LPCC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:MATTIS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2055
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-2055
Mailing Address - Country:US
Mailing Address - Phone:701-253-6300
Mailing Address - Fax:701-253-6400
Practice Address - Street 1:520 3RD ST NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2968
Practice Address - Country:US
Practice Address - Phone:701-253-6300
Practice Address - Fax:701-253-6400
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND626-3-1-09-185101Y00000X, 101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral