Healthcare Provider Details

I. General information

NPI: 1386719540
Provider Name (Legal Business Name): CHRISTINE M KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ALONA LN
LANCASTER WI
53813-2202
US

IV. Provider business mailing address

200 W ALONA LN
LANCASTER WI
53813-2202
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-6357
  • Fax: 608-723-4417
Mailing address:
  • Phone: 608-723-6357
  • Fax: 608-723-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number877-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: