Provider Demographics
NPI:1538228416
Name:MATHABELA, KELLY HAYWOOD (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:HAYWOOD
Last Name:MATHABELA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:HAYWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9019 WAGTAIL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5135
Mailing Address - Country:US
Mailing Address - Phone:512-799-3006
Mailing Address - Fax:
Practice Address - Street 1:2515 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5513
Practice Address - Country:US
Practice Address - Phone:512-854-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX392501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical