Provider Demographics
NPI:1457770398
Name:SUPINGER, KRISTA (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:
Last Name:SUPINGER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 W BROWN DEER RD UNIT G1202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2372
Mailing Address - Country:US
Mailing Address - Phone:414-745-9325
Mailing Address - Fax:
Practice Address - Street 1:333 W BROWN DEER RD UNIT G1202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-2372
Practice Address - Country:US
Practice Address - Phone:414-745-9325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3451103T00000X
AZ4467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100066773Medicaid
WIK400379168OtherMEDICARE