Healthcare Provider Details

I. General information

NPI: 1831223031
Provider Name (Legal Business Name): ALISA COLLEEN KELLY-MARTINA MSSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 RIVER ST
BELLEVILLE WI
53508-9189
US

IV. Provider business mailing address

107 EDWARD ST
VERONA WI
53593-1005
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-9100
  • Fax: 608-424-9099
Mailing address:
  • Phone: 608-424-0710
  • Fax: 608-424-9099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7189-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: