Provider Demographics
NPI:1437960390
Name:MATSOUKAS, KELLI LYNNE (LMSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNNE
Last Name:MATSOUKAS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W 64TH ST APT 20C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7149
Mailing Address - Country:US
Mailing Address - Phone:917-703-3517
Mailing Address - Fax:
Practice Address - Street 1:154 W 70TH ST APT 11B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-4406
Practice Address - Country:US
Practice Address - Phone:917-703-3517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087245104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker