Provider Demographics
NPI:1891436366
Name:KRISTA DEMUTH LLC
Entity type:Organization
Organization Name:KRISTA DEMUTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:715-410-1280
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:715-410-1280
Mailing Address - Fax:
Practice Address - Street 1:815 DAVIS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9808
Practice Address - Country:US
Practice Address - Phone:612-567-9881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083085914Medicaid
WI100059323Medicaid