Provider Demographics
NPI:1316189806
Name:STEWART, KELLY MARIE (LISW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7071 S 13TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1466
Mailing Address - Country:US
Mailing Address - Phone:414-502-8762
Mailing Address - Fax:
Practice Address - Street 1:7071 S 13TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1466
Practice Address - Country:US
Practice Address - Phone:414-502-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061751041C0700X
WI9777-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical