MEDICARE: KELLY MARIE STEWART LISW

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	1041C0700X	Clinical Social Worker	06175	IA
2	1041C0700X	Clinical Social Worker	9777-123	WI

General Provider Information

NPI Number	:	1316189806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE STEWART LISW

Provider Business Mailing Address
First Line	:	7071 S 13TH ST STE 100
Second Line	:
City	:	OAK CREEK
State	:	WI
Zip	:	53154-1466
Country	:	US
Telephone Number	:	414-502-8762
Fax Number	:

Provider Business Practice Location Address
First Line	:	7071 S 13TH ST STE 100
Second Line	:
City	:	OAK CREEK
State	:	WI
Zip	:	53154-1466
Country	:	US
Telephone Number	:	414-502-8762
Fax Number	:

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

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	05/14/2024

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