MEDICARE: KELLI BROSSART MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	131654-121	WI
2	1041C0700X	Clinical Social Worker	9798-123	WI

General Provider Information

NPI Number	:	1184275075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI BROSSART MSW, LCSW

Provider Business Mailing Address
First Line	:	5801 WASHINGTON AVE STE 201C
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-4057
Country	:	US
Telephone Number	:	262-900-1768
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 WASHINGTON AVE STE 201C
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-4057
Country	:	US
Telephone Number	:	262-900-1768
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2019
Last Update Date	:	07/12/2023

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