Provider Demographics
NPI:1184275075
Name:BROSSART, KELLI (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BROSSART
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 WASHINGTON AVE STE 201C
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4057
Mailing Address - Country:US
Mailing Address - Phone:262-900-1768
Mailing Address - Fax:
Practice Address - Street 1:5801 WASHINGTON AVE STE 201C
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4057
Practice Address - Country:US
Practice Address - Phone:262-900-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131654-121104100000X
WI9798-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker