Provider Demographics
NPI:1104329432
Name:MARTIN, KELSEY ANN (LCSW, CSAC, ICS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW, CSAC, ICS
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ANN
Other - Last Name:MADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1419 ISLAND ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2848
Mailing Address - Country:US
Mailing Address - Phone:920-420-4919
Mailing Address - Fax:
Practice Address - Street 1:571 BRAUND ST
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8556
Practice Address - Country:US
Practice Address - Phone:608-785-7000
Practice Address - Fax:608-785-7477
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI92241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100076316Medicaid