Provider Demographics
NPI:1699280206
Name:MARTIN, KELLI MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:TRAVILLIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:205 CHAMPION WAY STE 11
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2792
Practice Address - Country:US
Practice Address - Phone:859-323-6021
Practice Address - Fax:859-323-1670
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2551531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid