Provider Demographics
NPI:1730412032
Name:BELLECCI-ST.ROMAIN, LISA MARIETTA (LSCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIETTA
Last Name:BELLECCI-ST.ROMAIN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIETTA
Other - Last Name:BELLECCI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSCSW
Mailing Address - Street 1:221 S. BROADWAY
Mailing Address - Street 2:SUITE 608
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4213
Mailing Address - Country:US
Mailing Address - Phone:316-259-3160
Mailing Address - Fax:888-711-4131
Practice Address - Street 1:221 S. BROADWAY
Practice Address - Street 2:SUITE 608
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4213
Practice Address - Country:US
Practice Address - Phone:316-259-3160
Practice Address - Fax:888-711-4131
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4156 LSCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200631350AMedicaid