Healthcare Provider Details

I. General information

NPI: 1104329432
Provider Name (Legal Business Name): KELSEY ANN MARTIN LCSW, CSAC, ICS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY ANN MADER

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 BRAUND ST
ONALASKA WI
54650-8556
US

IV. Provider business mailing address

1419 ISLAND ST
LA CROSSE WI
54603-2848
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-7000
  • Fax: 608-785-7477
Mailing address:
  • Phone: 920-420-4919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9224
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: