Provider Demographics
NPI:1831223031
Name:KELLY-MARTINA, ALISA COLLEEN (MSSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:COLLEEN
Last Name:KELLY-MARTINA
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1005
Mailing Address - Country:US
Mailing Address - Phone:608-424-0710
Mailing Address - Fax:608-424-9099
Practice Address - Street 1:619 RIVER ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9117
Practice Address - Country:US
Practice Address - Phone:608-424-9100
Practice Address - Fax:608-424-9099
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7189-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40932200Medicaid