Provider Demographics
NPI:1801106265
Name:WITT-ERICKSON, KELLY JEAN (ICSW CPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:WITT-ERICKSON
Suffix:
Gender:F
Credentials:ICSW CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5213 WORCESTER LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:PRENTICE
Mailing Address - State:WI
Mailing Address - Zip Code:54556
Mailing Address - Country:US
Mailing Address - Phone:715-360-0809
Mailing Address - Fax:
Practice Address - Street 1:548 NORTH LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555
Practice Address - Country:US
Practice Address - Phone:715-339-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3898-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39706000Medicaid