Provider Demographics
NPI:1639421373
Name:DAY, KELLY J (LCSW,SAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:DAY
Suffix:
Gender:F
Credentials:LCSW,SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15501 INDIAN VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-1178
Mailing Address - Country:US
Mailing Address - Phone:715-369-7300
Mailing Address - Fax:715-369-7301
Practice Address - Street 1:533 PEACE PIPE ROAD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-0189
Practice Address - Country:US
Practice Address - Phone:715-588-1511
Practice Address - Fax:715-588-3903
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15508-131101YA0400X
WI129139-121104100000X
WI8996-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639421373Medicaid