Provider Demographics
NPI:1396801247
Name:SMITALA, MONIQUE PETRINE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:PETRINE
Last Name:SMITALA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:NIKKI
Other - Middle Name:PETRINE
Other - Last Name:SMITALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:N3189 ELTON SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:ELTON
Mailing Address - State:WI
Mailing Address - Zip Code:54430-9725
Mailing Address - Country:US
Mailing Address - Phone:715-882-3344
Mailing Address - Fax:
Practice Address - Street 1:612 CLERMONT ST
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-1942
Practice Address - Country:US
Practice Address - Phone:715-842-5577
Practice Address - Fax:715-845-8483
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1703-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39276900Medicaid