Provider Demographics
NPI:1083085914
Name:DEMUTH, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:DEMUTH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 KLEIN DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54015-9798
Mailing Address - Country:US
Mailing Address - Phone:612-567-9881
Mailing Address - Fax:
Practice Address - Street 1:600 DAVIS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9788
Practice Address - Country:US
Practice Address - Phone:612-567-9881
Practice Address - Fax:612-520-5821
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI6862-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor