Provider Demographics
NPI:1952668683
Name:MATHER, KELLY JAVIN DON (LCPC)
Entity Type:Individual
Prefix:
First Name:KELLY JAVIN
Middle Name:DON
Last Name:MATHER
Suffix:
Gender:M
Credentials:LCPC
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:104 9TH AVE S STE B3
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3852
Mailing Address - Country:US
Mailing Address - Phone:208-495-5806
Mailing Address - Fax:208-606-3680
Practice Address - Street 1:104 9TH AVE S STE B3
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3852
Practice Address - Country:US
Practice Address - Phone:208-495-5806
Practice Address - Fax:208-606-3680
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID6836101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor