Provider Demographics
NPI:1447358205
Name:HENRY, KELSEY MATTHEW (DC)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:MATTHEW
Last Name:HENRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 SOUTH SECOND ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:WV
Mailing Address - Zip Code:25260-9724
Mailing Address - Country:US
Mailing Address - Phone:304-773-5773
Mailing Address - Fax:304-773-5773
Practice Address - Street 1:1065 SOUTH SECOND ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:WV
Practice Address - Zip Code:25260-9724
Practice Address - Country:US
Practice Address - Phone:304-773-5773
Practice Address - Fax:304-773-5773
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV816111N00000X
OH3489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2657218Medicaid
WV3810003445Medicaid
OH2657218Medicaid
WVHE4168241Medicare PIN
WVBE9356391Medicare PIN