Provider Demographics
NPI:1396251013
Name:STAUTY, SANTANA RAE (LPC MS CRC)
Entity type:Individual
Prefix:
First Name:SANTANA
Middle Name:RAE
Last Name:STAUTY
Suffix:
Gender:F
Credentials:LPC MS CRC
Other - Prefix:
Other - First Name:SANTANA
Other - Middle Name:RAE
Other - Last Name:ROTHBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CRC
Mailing Address - Street 1:3001 US HIGHWAY 12 E STE 225
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3045
Mailing Address - Country:US
Mailing Address - Phone:715-231-2720
Mailing Address - Fax:715-232-5987
Practice Address - Street 1:3001 US HIGHWAY 12 E STE 160
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3045
Practice Address - Country:US
Practice Address - Phone:715-231-2743
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100079838Medicaid